Disaster response comes in many forms. It occurs in stages and involves many different agencies over an extended period. With current technology, meteorologists track the weather patterns leading to tornados and other severe storms, thus allowing for warnings, sometimes days in advance. Certain seasons are well known for the occurrence of natural disasters in specific areas, such as hurricanes in the Caribbean Basin, thus mandating appropriate preparedness during these times. Other disasters, such as those that are human-made, rarely allow for preparation and can result in a significant increase in morbidity and mortality. Regardless of the situation or its origin, one particular responding group can significantly affect the outcome of any disaster event: emergency medical services (EMS) personnel. Having a well-prepared EMS system that has been tested in disaster response decreases the morbidity and mortality associated with the event. From the moment an event unfolds, an emergency call is made, and multiple agencies respond, including police, fire, and ambulance personnel. The medical personnel on scene determine the gravity of the situation and often have to make life-and-death decisions, because resources may be quickly depleted in large-scale events.
Historical perspective
EMS today are largely the product of past civilian and military experiences, with current EMS principles and practices (particularly in the United States) evolving from wartime casualty care. The first-known organized use of ambulances was on the battlefields of Crimea, and the Vietnam War brought us the concept of the modern “field medic.” EMS history is undeniably rich in militaristic tradition, with practices documented as far back as 1500 BC, in Egypt. An ancient medical text known as the Edwin Smith Papyrus was used for military purposes. It describes injuries (wounds, dislocations, and fractures), presents a rational and scientific approach to the treatment of these injuries, and differentiates itself from other texts of the time, which were more based on magic than science. Each case detailed the type of injury, examination of the patient, diagnosis and prognosis, and treatment for the particular ailment. Treatments outlined included suturing wounds, controlling hemorrhage, and bandaging and splinting fractures. The document even described immobilization of the head and spinal cord in cases of injuries.
Baron Dominique Jean Larrey, Napoleon’s surgeon-in-chief, has been described as the father of modern military surgery. He mastered wound management, including early limb amputation (to prevent gangrene), and treated the wounded according to the severity of their wounds and not according to their rank within the military. He is also largely credited with placing the first ambulances in service (horse-drawn carts called ambulances volantes ), more than 150 years ago, during the Napoleonic War, rapidly evacuating wounded soldiers from the combat zone to aid stations and then to hospitals if needed.
During the U.S. Civil War (largely felt to be the starting point for EMS systems in the United States), a nurse named Clara Barton recognized that wounded soldiers of the Union Army were brought to facilities giving suboptimal care. She coordinated and rendered emergency care to wounded infantry, crusading tirelessly for the medical relief of sick and wounded soldiers, and quickly becoming known as the “Angel of the Battlefield.” After the war, Barton was introduced to the “Red Cross” in Geneva, Switzerland, and she established a branch within the United States. As the organization’s first president, she directed relief work for disasters, such as famines, floods, pestilence, forest fires, hurricanes, and earthquakes, in the United States and throughout the world.
Moreover, during the Civil War, it was also recognized that ambulances could be used on a daily basis to assist those in medical need. Some of the first cities in the world to adopt the use of the “ambulance” included New York City (NYC), London, Paris, and Cincinnati. During the late 1800s, ambulances in NYC were staffed with a medical intern and equipped with medicines, splints, bandages, and an array of other medical equipment.
With the improvement of military technology during the last century, casualties increased, necessitating training soldiers themselves to deliver EMS on the battlefield. During World War I, soldiers were taught basic medical management, as well as techniques in transport. In addition, the “Thomas Traction Splint” was introduced and used to stabilize leg fractures. This procedure alone was found to decrease morbidity and mortality in the field. Aeromedical transport systems were established during World War II and further refined during the Korean conflict, to expedite transfer of the wounded.
World War II resulted in a physician shortage in the United States because the doctors were pulled from ambulances and the medical community to serve their country, which abruptly resulted in untrained staff in ambulances throughout the United States. Although this shortage was problematic for urban areas, rural areas were especially hard hit, and ambulance services were commonly run by mortuary attendants. Throughout the 1950s and 1960s, it was obvious to many that there was a need to restructure the EMS model throughout the country. The Vietnam War is widely considered a time when trauma protocols and interventions helped to shape the current approach to prehospital care. The corpsman of Vietnam most closely resembled the “paramedic” of today, with personnel being well trained in a variety of advanced medical interventions. It was clearly documented that battlefield mortality rates decreased significantly with the evolution of trauma care, early advanced interventions, and expeditious transport from the front lines to definitive care via helicopter. Casualty rates for U.S. soldiers were clearly reduced as follows: 8% during World War I, 4.5% during World War II, 2.5% during the Korean War, and less than 2% during the Vietnam conflict. The shift from empiricism to the practice of evidence-based medicine and the provision of acute care in the field clearly made armed conflict much more survivable. The immense benefits of rapid, advanced field stabilization and swift transport to definitive care facilities would soon become the expectation of politicians and civilians alike in the United States.
Throughout the 1960s, numerous studies throughout the world showed that prehospital CPR with defibrillation and medication administration was found to make a difference (20% resuscitation success was reported by a group in Ireland). , Such data helped politicians, physicians, and interested parties make the case for a more integrated and sophisticated EMS system. Researchers in the United States during the early 1960s further found that an infantry soldier in Vietnam had a statistically greater chance of survival than the average citizen involved in a motor vehicle collision on any of the nation’s highways had. This single disparity prompted two significant legislative acts in 1966 in the United States. First, the National Academy of Sciences-National Research Council (NAS-NRC) published Accidental Death and Disability: The Neglected Disease of Modern Society . This white paper put forth 24 recommendations to improve care for injured persons, and it served as a blueprint for the development of EMS. Recommendations included disaster planning, regulation of EMS by the states, development of trauma registries, the creation of various standards within EMS for training, public safety infrastructure improvements, emergency department overhauls, and the creation of “…a single nationwide number to summon an ambulance.” It also went on to recommend that emergency departments be staffed with more-experienced personnel and be categorized and that they should collect data on select injuries. The second bill prepared by Congress was the Highway Safety Act of 1966. It mandated the creation of the U.S. Department of Transportation (USDOT) and the National Highway Traffic Safety Administration (NHTSA). Both entities provided legislative authority and financial assistance to EMS systems in the United States. Since the 1960s, EMS have been evolving throughout the United States, with current governance being through local, regional, and state protocols. Prehospital care is largely delivered through a variety of options, with emergency medical technicians (EMTs) and fire personnel predominantly providing this service.
Over the past 50 years, EMS systems worldwide have evolved, and they continue to evolve today. Many countries do not have a robust system such as those found in the United States, Europe, and Australia. Internationally, disasters continue to happen, resulting in an international response, because local resources are quickly outstripped. The bombings in Europe (e.g., Spain, England), the coordinated acts of 9/11, and the violence throughout Africa and some Arab countries bring to light the need for emergency preparedness and a proper disaster response to human-made disasters. Natural disasters continue to occur at an alarming rate (Haiti, 2010; Cyclone Nargis in Myanmar, 2008; the Pakistan Earthquake, 2005; Hurricane Katrina, 2005; the Tohoku Earthquake and Tsunami, 2011; the Philippines Super Typhoon, Haiyan, 2013; the New Zealand Earthquake, 2011; the East Africa Drought, 2011; the European Heat Wave, 2003), with many of the worst recorded natural disasters in the history of the world occurring in the past 20 years. Worldwide, it has been recognized that the EMS response must be coordinated and efficient, necessitating the need for training and preparedness of EMS personnel. In the United States, federal guidelines and regulations have become more integrated after 9/11 because disaster response and mitigation are both extensively discussed and drilled. In addition to having highly skilled and trained personnel, it has been well recognized that a highly organized structure for disaster response is necessary to respond in the most effective manner to any disaster situation. There is no better example of how a disaster situation can be further negatively affected, than the historic 9/11 attack on the World Trade Center in 2001. New York City’s Office of Emergency Management (OEM) was headquartered at Seven World Trade Center, with communications from the city’s OEM based on the rooftop of One World Trade Center. , Less than 9 hours after the first strike, Seven World Trade Center collapsed, resulting in a lack of radio frequency interoperability among EMS, the New York Police Department, and the Fire Department of New York. Triage and transport of patients were adversely affected by the lack of coordinated communications with local and regional hospitals in the NYC metropolitan area. ,
Although EMS in the United States developed largely from the frontline medical practices of the Vietnam War, the Incident Command System (ICS) was developed in the early 1970s, by fire administrators in California, to manage better the rapidly moving wildfires and operational deficits previously encountered. Specific complications cited before the creation of the ICS included too many people reporting to one supervisor, different emergency response organizational structures, lack of reliable incident information, inadequate and incompatible communications, lack of structure for coordinated planning among agencies, unclear lines of authority, terminology differences among agencies, and unclear or unspecified incident objectives. In 1980, U.S. federal officials recognized the importance of the ICS and realized that it could easily be incorporated on a national level to help with disaster response. In the United States, the National Interagency Incident Management System (NIIMS) was created. Since then, it has been adapted further for use in disaster response in the United States. The inherent flexibility of the ICS to accommodate issues of incident size and utilization of available resources has allowed the system to be used to mitigate both minor crises and major disasters exacted by nature and humans alike. As public safety personnel developed familiarity with the ICS, the federal government identified the need for the development of a body of government to establish standards of practice within increasingly complex applications of disaster management. In response to the increasing threat of terror attacks and the need to ensure a more cohesive response to large-scale incidents, federal guidelines were created to establish the role of EMS. ,
In 1998, Congress issued a report underscoring concern regarding “… the real and potentially catastrophic effects of a chemical or biological act of terrorism.” Legislators indicated that, although the federal government is integral in the prevention and secondary response to such incidents, state and local public safety personnel who respond initially require additional assistance. The Appropriations Act (Public Law 105-119) authorized the U.S. attorney general to aid state and local responders in acquiring specialized training and equipment to “… safely respond to and manage terrorist incidents involving weapons of mass destruction (WMD).”
Shortly after the attacks on September 11, 2001, the largest and most expensive reorganization of the U.S. federal government in history occurred, resulting in the formation of the Department of Homeland Security (DHS). While less than 4% of the total funding was allocated toward EMS, the functions of the newly created offices included incident management and oversight of preparation, response, and recovery after terrorist incidents. The Homeland Security Act of 2002 placed DHS in command of 22 government agencies, including the Federal Emergency Management Agency (FEMA).
EMS internationally
The terms EMS and prehospital care are often used to describe services systems at the provider, ambulance service, community, region, state, or even national levels. Comparisons of EMS systems are difficult because EMS systems have traditionally been developed based on the unique local needs of their community, which has led to the many different classifications of EMS systems in use globally. Regardless of the place on this planet, EMS systems often have common principles and practices, although the structure may be very different. Generally, EMS involve trained personnel responding to care for another person in medical need, as well as the use of a vehicle and common equipment and the need for expertise in managing emergency medical issues. Whereas new EMS systems are created both locally and internationally, and existing systems improve, implementing best practices that work globally is essential. Classifications of EMS systems are therefore necessary so that similar systems can be compared, and concepts such as quality improvement and best practices can be established.
As outlined in “EMS: A Practical Global Guidebook,” EMS systems can be classified based on how the service is regulated :
- 1.
National system: EMS systems administered by national governments or ministries
- 2.
Local or regional system: EMS systems administered by local or regional governments, often as a part of local or regional police or fire departments
- 3.
Private system: Systems in which private EMS companies contract with local, regional, or national governments to provide prehospital care
- 4.
Hospital-based system: EMS system based at and/or run by central or referral hospitals
- 5.
Volunteer system: Common in smaller, rural areas, where the systems rely on community volunteers, who donate their time to provide local prehospital care
- 6.
Hybrid system: EMS systems that combine some or all of the features of the above-mentioned systems
EMS systems can also be classified based on the level of care provided by the many types of providers in the ambulance. The service can be:
- 1.
Unorganized: Common in developing countries, in these systems, the sick and injured are transported to the hospital in a nonorganized manner, by an unstructured system, and often by bystanders who have no knowledge of medicine and who transport the person via a personal vehicle. Providers may or may not have official training or certification, and the vehicles are not regulated.
- 2.
Basic life support (BLS): These systems consist of essential noninvasive life-saving procedures (CPR, artificial ventilation/oxygenation, basic airway management, hemorrhage control, extremity splinting, spinal immobilization, and vital signs).
- 3.
Advanced life support (ALS): BLS skills as well as more-advanced invasive life-saving procedures (advanced airway adjuncts, intravenous infusions, medication administration, defibrillation, electrocardiogram interpretation, community paramedicine, etc.) are included.
- 4.
Physician service: In these systems, a physician staffs the ambulance or a car and responds as part of the ambulance crew to evaluate and provide care on scene. The physician may opt to treat on scene and not take the patient to the hospital or to take the patient into the hospital for treatment.
Even within these classifications, it is difficult to compare the quality of medical care because the providers at each level have a variety of training, and the “EMS system” differs from country to country, depending on the financial resources available. The doctors in physician-led services may not actually be emergency-trained physicians and may not even have experience as physicians before being allowed in the ambulances (they may still be interns or recent medical school graduates with no residency training). In ALS systems, EMS provider certifications vary, not only from state to state but also country to country. This can make credentialing difficult. In some local systems, physicians can mandate their own individual standards and expectations, making it difficult for EMS personnel to have a standard when treating patients in the prehospital environment. More importantly, the lack of a standardized system can result in increased morbidity and mortality for patients for a number of reasons. These include lack of skill maintenance, difficulty with maintaining quality assurance, varied authorizations to perform advanced procedures, varied medications to administer and learn, and varied “whims” by different medical directors.
EMS systems around the world can generally be divided into two main models: the Franco-German model or the Anglo-American model. The Franco-German model of EMS delivery is based on the “stay and stabilize” philosophy. The motive of this model is to bring the hospital to the patient(s). It is usually run by physicians, and they have extensive scope of practice with very advanced technology. The model utilizes many methods of transportation alongside land ambulances, such as helicopters and coastal ambulances. This model is usually a subset of the wider health care system. This philosophy is widely implemented in Europe, where emergency medicine is a relatively young field. Throughout Europe, prehospital emergency care is usually provided by “emergency physicians,” although this specialty is not officially recognized in many countries as it is in the United States. The physicians in the field have the authority to make complex clinical judgment and treat patients in their homes or at the scene. Under this system, many EMS users are treated on-site and not transported to a hospital. In some systems, patients who are transported to a hospital can be directly admitted to hospital wards (including ICUs) by the attending field physician, thereby bypassing the emergency department. Countries such as Germany, France, Greece, Malta, and Austria have well-developed Franco-German EMS systems. Italy has a system made up of predominantly volunteer BLS ambulances, with physician ALS ambulances to augment with advanced interventions when it is determined that these services are needed on scene.
In contrast to the Franco-German model, the Anglo-American model is based on a “scoop and run” philosophy. This model aims to bring patients to the hospital rapidly, with fewer prehospital interventions. It is usually allied with public safety services (police or fire departments) rather than public health services and hospitals. Trained paramedics and EMTs run the system with medical oversight. The model relies heavily on land ambulances and less so on aeromedical evacuation or coastal ambulances. In countries following this model, emergency medicine is well developed and generally recognized as a separate medical specialty. Almost all patients in the Anglo-American model are transported by EMS personnel to developed emergency departments rather than hospital wards. Countries that use this model of EMS delivery include the United States, Canada, New Zealand, the Sultanate of Oman, and Australia.
Many studies have attempted to compare the two systems in terms of outcome or cost-effectiveness. This is essentially futile because each model tends to operate very differently, as the demands and expectations of the community are ultimately what must be met. In addition, the lack of unified standards between the two models makes comparison an unjustifiable exercise. There is currently no evidence that one model is “better” than the other is, and studies continue to show conflicting conclusions, despite the personal beliefs and experiences of physicians, nurses, and EMS personnel worldwide. ,
Currently, most countries have no developed EMS system. International EMS systems have varied features and practices, but they all resemble the main models of EMS systems in one way or another. Countries that are recognizing emergency medicine and prehospital care as new specialties and building EMS systems often find themselves having to choose between the two models. Others are more creative and use concepts of both, thus creating hybrid systems that incorporate features of both models.
The World Health Organization regards EMS systems as an integral part of any effective and functional health care system. , EMS (no matter the form) is the first point of contact globally for the majority of people to health care services during emergencies and life-threatening injuries. In many countries, EMS is the “gate-keeper” for access to specialty hospitals, according to the injury or illness identified. Emergency medical providers around the world continue to learn and utilize advanced clinical technology while they care for medical and trauma emergencies. The goal of any international EMS system must be to adapt a model and create a system that meets the local needs, works with regional health care resources, and is sensitive to the local and national customs, while working within the political and financial structure in each individual community. In addition, the EMS community must keep in mind that a well-practiced and trained EMS system is what makes all the difference in the morbidity and mortality associated with any disaster scenario ( Table 3-1 ).
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