From the time a call is received, several questions should go through the EMT's head:
- What problems may be encountered?
- Will there be any hazards to me or my partner?
- Who has been identified as the team leader for this call?
- What will need to be done first?
- Is this a residence, business, wilderness, etc.?
- What is noticed when surveying the scene?
- What are the priorities when starting to treat this patient?
- Can the situation be handled with the available resources?
- Which emergency department should be the destination hospital?
Types of Calls
Different EMS systems may have a higher percentage of specific types of incidents but, the EMT must be prepared to identify and manage patient problems and rank them by severity. The ultimate goal is to provide efficient, high-quality patient care. The EMT must rapidly stabilize the patient and choose the hospital that will best meet the patient's needs.
About 1 million Americans die every year from cardiovascular disease. Approximately half of these deaths are due to coronary artery disease with around 300,000 being sudden deaths. About 160,000 of these deaths occur in patients under the age of 65 years. These make up about one third of the calls an EMT will respond to.
Trauma is the leading cause of death in the first half of the life's span. It is the leading cause of death for children and adults under the age of 45 years, and the third leading cause of death for all age groups. Trauma patients are usually younger than those experiencing cardiovascular illness.
Even though pediatric patients make up about 30% of the population, they only account for 10% of the calls for EMS. Accidental injuries are the leading cause of death in children over the age of 1 year. Other causes of death include drowning, burns, child abuse, and poisoning. Calls for respiratory difficulty and seizures will be the most common medical problems. Motor vehicle accidents (MVA's) and falls will account for the bulk of the injuries. Calls for injuries are most common during the early morning to mid-afternoon (school) hours. Medical calls are most likely received during the afternoon and evening hours.
Currently, 11% of the population in the U.S. is made up of people over the age of 65 years. The major cause of illness and death in the geriatric population are related to cardiovascular disease, cerebrovascular accidents (CVA's or "strokes"), altered mental status, and pneumonia. Trauma is the fifth leading cause of death in the elderly with falls the leading cause of trauma deaths and disability. Medications taken by the elderly may have different reactions than in the younger patients. Due to metabolism changes, drug doses need to be reduced by one third to one half of the usual adult dose. A polypharmacy situation may exist, in which medications are either over prescribed, taken in very high doses, or may be given to them by a well-meaning friend.
This population of patients has been previously referred to as handicapped or disabled persons. The EMT must take extra time to assure these patients and to make them comfortable.
Citizen Access and Communication
ny call for EMS begins with citizen access. Only a few states have 100% 9-1-1 access. Cellular technology has allowed citizens to access 9-1-1 from mobile or cellular phones which reduces lost valuable time. Cellular technology has been introduced in many EMS services around the country. The key to minimal delay rests with the initial access and ongoing communications that occur between the EMT in the field and the emergency physician at the hospital.
The goal for most EMS systems is to have an EMT crew on the scene within 4-6 minutes from the time the call is received at the emergency communications center. EMDs decide the level of care by following established medical criteria. One of several commercially available EMD programs is called criteria-based dispatch (CBD). Additionally, computer-aided dispatch (CAD) systems combine both pre-arrival instructions and priority dispatch and being integrated into EMS communications systems.
After receiving the dispatch order from EMD, obtain as much information as possible to help prepare for the scene. Questions include:
- Type of call?
- Age and sex of patient?
- Location of the incident?
- How long ago did the incident occur?
- Any first responders or law enforcement personnel on the scene?
- Has an advanced life support ambulance been dispatched?
- Number of patients?
- Time dispatched?
The EMT should think about how to gain access to the patient as quickly as possible. A mental picture should be formed while still in the ambulance en route. Scene priorities should be reviewed which include:
- What equipment will most likely be needed?
- What is the worst problem that might be encountered?
- What should the EMT expect from the patient, family, friends, etc.?
- What kind of questions will be asked of the patient?
- What are the roles of each team member?
- What treatment or stabilization procedures will be required?
The first concern on the scene is the safety of the crew. The EMT should consider the following questions:
- Has the scene been appropriately marked with safety lights or flares?
- Are flammable liquids present?
- Are hazardous materials involved?
- How many patients are involved?
- Is there any entrapment?
- Are law enforcement personnel on the scene?
- Has area been secured by law enforcement personnel?
- Does patient have a single injury or multiple wounds?
- Is more than one patient present?
- Who are the victims and the assailants?
- Where are the weapons?
- Never enter a scene without proper back-up support, if danger is present.
Appropriate scene control is the responsibility of police, fire, and EMS personnel. Communication and cooperation of agencies is vital to a smooth operation. If conflicts still exist at the scene, they must be dropped while on the scene. You are on the scene for the patient.
The most challenging situation is the mass casualty incident in which large numbers of patients are injured or killed, such as after an earthquake, flood, tornado, etc. Weather conditions while treating the patient may also threaten the EMT. If the need arises, take a moment to adjust the environment to allow for an easier working situation. Moving the patient affords some privacy and protects the patient and crew from inclement weather. If no other patients are involved, transportation can begin while patient care is started. This will shorten the time to definitive care. In some situations, the EMT may need to adjust to changing environmental conditions, crowd positions, structural changes, or other circumstances that increase the hazard to patient and crew.
Taking Command of the Scene
In an emergency situation, the need to delegate authority is critical. An EMT learns to lead by following the examples set by other leaders and being sensitive to the cues sent forth by these leaders. The EMT must come to emotional grips with being a leader. EMS must be a paramilitary organization to properly function. Unless the EMT is able to influence people to make things happen, no action will occur.
Communication is a form of influence. It involves a relationship in which all parties play distinct but complementary roles. The purpose of effective communication is the transmission of information. It will take the form of face-to-face conversations with the patient, family, bystanders, and staff, written reports, radio transmissions, memos, or other directives.
A good EMT assists the remote physician in developing a mental picture of what is occurring. All of the information gathered by the EMT during the various phases of assessment must be documented and communicated to the emergency department staff accurately and quickly.
Transportation is an intervention that must be prioritized like other interventions and accomplished in a safe manner. Choosing one hospital over another depends on patient request, proximity, specialized care, emergency department patient diversion status, and local protocols. Usually a helicopter is warranted if rapid access to a higher level of care is required (hospital to hospital) or for scene response when hospital access time to the correct hospital can be shortened.
After arrival at the emergency department (ED), the EMT must report to and discuss the findings and treatment rendered with the nurse and emergency physician. It is important that the EMT remain with the patient throughout the transfer process in the ED.
After the EMT leaves the hospital, the only way the ED staff can determine what happened prior to arrival is through the prehospital care report (PCR). It is imperative that all findings be documented and that any valuables or personal effects be left with the ED staff. Remember, what is not documented on the PCR is assumed not to be done.
Before leaving the ED, the EMT should make sure that the ambulance is prepared in the event that another incident occurs. Once everything is disposed, cleaned, and disinfected, and the EMT reports "clear and available" to the dispatcher, the EMT must be prepared to respond to the next EMS call.
Continuum of In-Hospital Care
Ultimately, the patient's return to normal function ina timely and productive fashion will depend on the prehospital care delivered by the EMT as well as the care delivered by the other members of the healthcare team in the hospital. An EMT should be aware of what services are offered in the local hospitals.
1. Number the following call segments in the correct sequence in a traditional EMS response:
Continuing in-hospital care
Citizen access to EMS
Dispatching the ambulance
Scene assessment and control
Interaction with the patient
2. Is it critical that the EMT know if a scene is unsecured? Why?
3. Whose responsibility is scene control?
4. What are the ways in which an EMT communicates?
5. When is the patient considered for transportation?