This book is dedicated to the premise that emergency medical services (EMS) represent a bona fide field of physician subspecialty, that certain knowledge and skills are required, and that there is broad interest in learning about these matters. This chapter describes the subspecialty and begins the process of providing clarity to the roles of an EMS physician and the practice of EMS.
THE BASIS FOR A SUBSPECIALTY
Indeed, since the earliest developments of EMS there have been physicians who applied their expertise to the nuances of providing care to the ill and injured in the field. They came from diverse clinical backgrounds, but they shared perspectives that optimal care provided as soon as a life-threatening condition could be recognized provided opportunities for improved outcomes. Though they may not have thought of themselves as such, they were the pioneer EMS subspecialists.
The next chapter will provide a historical overview of EMS. Among the various milestones of EMS development, there was generally a physician using his clinical knowledge, understanding of pathophysiology, and patients’ needs to prompt innovation and advances of all sorts. Some might be considered logistical, such as when Jean Dominique Larry, Napoleon’s chief military physician, built “ambulance volantes” to evacuate wounded soldiers from the battlefield.1 Others might be considered clinical advances, such as the development of cardiopulmonary resuscitation (CPR) or Dr Frank Pantrindge’s delivery of life-saving defibrillatory shocks to patients not yet at a hospital.2,3 Still, others advanced the concept of medical oversight, as were the lessons of Drs Cobb and Copass in Seattle. Collectively, these examples help reveal the breadth of knowledge and skill required among EMS subspecialists.
Nevertheless, for some time there was a considerable struggle to define the nature of the EMS subspecialty and designate it as such. Among the challenges was the necessary distillation of a multifaceted and blended discipline to reveal and capture its clinical essence, upon which various administrative and health care management roles may be layered. That culminated on September 23, 2010, when the American Board of Medical Specialties (ABMS) officially recognized EMS as a physician subspecialty as requested by the American Board of Emergency Medicine (ABEM). The journey to that point is revealing, and in some respects is not unlike the path to recognition of emergency medicine as a specialty with its own unique fund of knowledge and purview.
The often-cited 1966 paper Accidental Death and Disability: The Neglected Disease of Modern Society pointed out a number of shortcomings in the American health care system related to trauma and emergency care.4 John M Howard, MD, was an army surgeon during the Korean Conflict and one of the paper’s authors. He has recalled that the impetus for the study and a report of its findings was the observation by him and similar physicians that the lessons learned in Korea had not translated to home in the United States.5 The American health care system remained woefully ill prepared to deal with what was described as an injury epidemic.4 At the time, although new patterns of staffing hospital emergency departments were evolving, many hospitals required all medical personnel, regardless of specialty, to share emergency department responsibility. The 1966 paper proclaimed that no longer can emergency department responsibility be assigned to the least experienced member of the medical staff or solely to specialists who, by the nature of their training and experience, cannot provide adequate care without the support of other staff members.4 Indeed, emergency department care represented early intervention in the continuum of care required by seriously ill or injured people. It demanded special expertise and both breadth and depth of clinical skills and knowledge. Subsequently, the Emergency Medical Services Act of 1971, among other things, made “seed money” available to help develop new emergency medicine residency programs.6 Emergency medicine became recognized as a primary board by ABMS in 1979.
Part of the rationale for emergency medicine to be a distinct specialty rested in its interface with EMS systems and personnel. While care in an emergency department was undoubtedly early in the continuum, care in the field was earlier and it required active oversight by physicians with attentive interest and appropriate insights. At the time, EMS often represented the notion of taking the emergency department to the patient. Thus, by natural extension emergency physicians became the most active physician participants within EMS systems, offering a distinction from the rest of medicine.
EMS, as we know, has evolved. The need for specific expertise has intensified. It is no longer acceptable to uniformly bring the emergency department to every patient. Whether or not a specific intervention or pharmaceutical agent ought to be translated from the emergency department to out-of-hospital scenes requires careful analyses of risks and benefits and cost-effectiveness in the context of local circumstances. Decisions regarding use of thrombolytics, neuromuscular blocking agents, and even steroids are all examples. These sorts of analyses are done on a patient-by-patient basis numerous times a day by physicians of all genres. However, the knowledge and perspectives required by these specific questions and those like them have demanded special expertise and understanding the needs of EMS patients and the intricacies of often complex EMS care delivery systems.
As defined by the Institute of Medicine of the National Academies, EMS comprises the crucial early phases of the continuum of emergency medical care for acutely ill and injured persons. It encompasses prehospital and out-of-hospital emergency care, including 9-1-1 access and dispatch, field triage and initial stabilization, and treatment and transport in specially equipped ambulances or helicopters to hospitals or between medical facilities.7
EMS physicians provide emergency medical care for patients in out- of-hospital settings and medical oversight of EMS systems. According to ABEM, the unique clinical elements that characterize EMS medical practice stem from its position early in the continuum of patient care, its physical location outside of fixed medical facilities, and the relatively higher acuity of its patient population compared to emergency medicine. The treatments developed by EMS physicians, and either delivered or overseen by them, affect patients’ ultimate outcomes as patient safety and proper treatment are ensured.8 It is the EMS physician who brings medical decision making to the patient’s side at the site of accident or injury, ensuring appropriate care until arrival at a hospital or other advancement further in the continuum of care. According to ABEM, the purpose of subspecialty certification in EMS is to standardize physician training and qualifications for EMS practice, to improve patient safety and enhance the quality of emergency medical care provided to patients in the prehospital environment, and to facilitate integration of prehospital patient treatment into the continuum of patient care.8
In 2011, ABEM published The Core Content of EMS Medicine. It incorporates four principal topic categories (Table 1-1) that include more than 400 total elements.9 Each element relates to one or more core competencies as described by the Accreditation Council for Graduate Medical Education and ABMS, including patient care, medical knowledge, practice-based learning, professionalism, interpersonal skills, and system-based practice.10