Emergency medical services in the United States



Emergency Medical Services (herein, EMS) in the United States is regulated at its most basic level by the federal government, who sets the minimum standards that all states must meet; but much more strictly by individual state governments, who often require higher standards of the services they oversee. Additionally, wide differences in population density, topography, and other conditions demand or allow for different types of EMS systems. Consequently, there is real variation between the EMS provided in one state and that provided in another.

History
Prior to the 1970s, ambulance service was largely unregulated, and while some areas ambulances were staffed by advanced first-aid level responders, in other areas, the ambulance was a hearse, and its driver was an untrained mortuary attendant. However, after the release of the National Highway Traffic Safety Administration's study, "Accidental Death and Disability: The Neglected Disease of Modern Society", (known in the EMS trade as the White Paper) a concerted effort was undertaken to improve emergency medical care in the prehospital setting.

In the late 1960's, Dr. R Adams Cowley was instrumental in the creation of the nation's first statewide EMS program in Maryland, the Division of Emergency Medical Services (now known as the Maryland Institute for Emergency Medical Services and Systems). At the same time, in 1969, Cowley was successful in obtaining a military helicopter for the purpose of rapidly transporting patients to the Center for the Study of Trauma, a specialized hospital that he had started for the purpose of treating shock now know as the R Adams Cowley Shock Trauma Center. This service was not only the first statewide EMS program, but also the beginning of modern emergency medical helicopter transport in the United States.

The first civilian hospital-based medical helicopter program in the U.S., Flight For Life Colorado began in 1972 with a single Alouette III helicopter, based at St. Anthony Central Hospital in Denver, Colorado.

National EMS standards for the US are determined by the U.S. Department of Transportation and modified by each state's Department of EMS (usually under its Department of Health), and further altered by Regional Medical Advisory Committees (usually in rural areas) or by other committees or even individual EMS providers. In addition, the National Registry of Emergency Medical Technicians, an independent body, was created in 1970 at the recommendation of President Lyndon B. Johnson in an effort to provide a nationwide consensus on protocols and a nationally accepted certification. National Registry certification is widely accepted in some parts of the U.S., while other areas still maintain their own, separate protocols and training curricula.

A significant event in the development of modern standards of care in the U.S. was a report published in 1966 by the National Academy of Sciences entitled Accidental Death and Disability: The Neglected Disease of Modern Society, commonly referred to as "the White Paper." In this study, it became apparent that many of the deaths occurring every day were unnecessary, and could be prevented through a combination of community education, stricter safety standards, and better pre-hospital treatments.

In particular, in the US state of California and in Seattle, Washington state (see Medic One), projects began to include paramedics in the EMS responses in the late 1960s. Groups in Pittsburgh, Pennsylvania and Portland, Oregon were also early pioneers in prehospital emergency medical training. Despite opposition from firefighters and doctors, the program eventually gained acceptance as its effectiveness became obvious. Furthermore, such programs became widely popularized around North America in the 1970s with the television series, Emergency! which in part followed the adventures of two Los Angeles County Fire Department paramedics as they responded to various types of medical emergency. James O. Page served as the series technical adviser and went on to become integral in the development and EMS in the U.S. The popularity of this series encouraged other communities to establish their own equivalent services.

Certification level
EMS providers work under the authority and indirect supervision of a medical director or board-certified physician who oversees the policies and protocols of a particular EMS system or organization. Due to the nature of the environment in which EMS personnel must work, equipment and procedures are necessarily limited; however, prehospital personnel are able to provide a high level of advanced care.

EMS professionals are trained to follow a formal and carefully designed decision tree, more commonly referred to as a protocol, which has been approved by the Medical Control Physician. This protocol helps ensure a consistent approach to the most common types of emergencies the EMS professional may encounter.

The lines between one level of care and the next are becoming increasingly blurred. Skills that were once reserved for physicians are now routinely done by paramedics, and skills once reserved for paramedics, such as defibrillation, are now routinely done by Basic Emergency Medical Technicians (EMTs). There is also wide state-to-state and even county-to-county variation of what types of care providers at different levels are allowed to provide. Finally, some states and counties alow for add-ons, such as defibrillation or IV therapy, which enable workers to learn and use additional skills without having to take all of the schooling to advance to the next level of certification. (Example: An EMT-Basic may not be able to start an IV, but by successfully completing an IV add-on course, she would then be able to do so.) That said:
 * Certified first responder (CFR): CFRs, many of whom are volunteers, render very basic first aid, including oxygen administration to patients. Generally, a CFR cannot assume care for a patient while that patient is being transported.
 * Emergency Medical Technician (EMT): EMT is used two different ways. Technically, an EMT is a person who has been certified (or licensed, in some states) to provide a stated level of care based on written protocols. EMTs may be divided into several groups, based on their level of certification:
 * EMT Basic (EMT-B): Provides Basic Life Support (BLS) care, such as oxygen therapy, Splint (medicine), bleeding control, defibrillation with an AED, and light extrication (eg: removing a victim from a car, but not using the jaws of life.)
 * EMT Intermediate (EMT-I): not found in all states. EMT-Intermediates provide BLS care with the addition of IV therapy, and often intubation.
 * EMT Paramedic (see also Paramedics in the United States): EMT-paramedics provide all of the care provided by EMT Intermediates, plus manual defibrillation and advanced electrical therapy including transcutaneous pacing (fitting a temporary pacemaker to the patient's chest) and synchronized cardioversion (an advanced form of defibrillation), intubation, medication administration, pleural (chest) decompression, and more.
 * EMTs other than EMT-Bs often prefer to be identified based on their level of certification, so an EMT-P might be called a paramedic or an EMT-P, but rarely an EMT. EMT, when used alone, may therefor also mean EMT-B.

In addition to the Paramedic level, Critical Care Paramedics specialize in the management of critical trauma and medical patients during interfacility ground and aeromedical transports to include: ventilator management, IV pump infusion maintenance, aortic balloon pump monitoring, and specialized hemodynamic monitoring.

Ambulances in the United States are often staffed by at least two crewmembers. Many areas require that at least one crew member be a certified or licensed EMT, enabling this person to continue to provide medical care while the other crewmember drives the ambulance to transport the patient to the hospital.

In certain states other classifications exist, such as in New York, where there are 5 levels of EMS: CFR, EMT, AEMT-Intermediate, AEMT-Critical Care, and AEMT-Paramedic. Virginia has an EMT-Enhanced level as its entry-level ALS provider role, although this certification is not used in all local jurisdictions. Iowa has 5 EMT provider levels: First Responder, EMT-Basic, EMT-Intermediate, EMT-Paramedic and Paramedic Specialist. As there are other specializations of EMTs in certain states, some also do not recognize certain level either. Missouri is one of those states in which the EMT-I is not recognized as a level of the EMS system.

Ambulances


Ambulances in the United States are defined by federal KKK-1822 requirements, which define several categories of ambulances, althought most states have additional requirements that are added to meet their individual meeds: AD (Additional Duty) versions of both Type I and Type III designs are also defined. They include increased GVWR, storage and payload capacity.
 * Type I Ambulances are based on the chassis-cabs of light duty pickup-trucks,
 * Type II Ambulances are based on modern passenger/cargo vans, also referred to as Vanbulances,
 * Type III Ambulances are based on chassis-cabs of light duty vans,

Large American cities like New York and Los Angeles tend to have many distinct ambulance services, each with its own paint scheme, using all of the ambulance types mentioned above, so pedestrians and drivers must be alert for ambulances of many shapes, sizes, and colors. Most ambulances certified for emergency response in the U.S. are marked with the Star of Life for ready identification by the public.

Nontransporting vehicles
Ambulances may be supplemented or supported by vehicles that lack the capacity to transport a patient. The most common of these vehicles is known by several names, including fly-car. Fly cars are often equipped with much of the equipment carried by an ambulance, but, since they are SUVs or large cars, they are often faster and nimbler. Fly-cars are staffed by one or more medical providers, and are used variously as a source of additional (or more skilled) manpower, as a supervisor's vehicle, or as a first response vehicle, enabling medical treatment to begin before the arrival of the ambulance.

Organization and Funding
EMS in the US is delivered through various models. These include;
 * Public EMS
 * Municipal/City run
 * Independent Volunteer Squad run
 * Third Service stand alone
 * Third Service hospital based
 * Fire Service fully integrated and cross-trained
 * Fire Service based, non-integrated (includes volunteer fire services)
 * Police service based, includes Sheriff's Offices (Police and Fire Services being the first two emergency services)
 * Private EMS
 * large national companies
 * Regional companies
 * Small local "mom and pop" companies, and
 * Funeral homes in some places, once the largest providers.

Funding and manpower models include:
 * Volunteer Public, non-billing, subsidized by property or sales taxes
 * Volunteer Public, non-billing, subsidized by donations
 * Volunteer Public, calls billed, partially subsidized through property or sales taxes
 * Volunteer Public during nights and weekends and per diem paid during weekdays with combination billing.
 * Full time paid Private Enterprise, calls billed, partially subsidized through property or sales taxes
 * Full time paid Private Enterprise, calls billed, no subsidy
 * Full time paid Public Utility Model, calls billed, usually no subsidy

EMS is largely provided by volunteers outside of major cities. But due to the increasing intensity of training, EMS is becoming more of a paid profession. Even agencies that were once strictly volunteer have begun supplementing their ranks with compensated members in order to keep up with booming call volumes. As of 2004, the largest "Private Enterprise" provider of contract EMS services in North America is AMR or American Medical Response, based in Greenwood Village, Colorado. The second-largest US EMS provider is Rural/Metro Corporation, based in Scottsdale, Arizona; they also provide EMS services to parts of Latin America. Like AMR, Rural/Metro provides other transportation services, such as non-emergency transport and "coach," or wheelchair, transportation.

Many colleges and universities now also provide their own EMS agencies for their campuses. Collegiate EMS programs vary somewhat from university to university, however most agencies are fully staffed by student volunteers. Agencies may operate what is called a Quick Response Service (which do not transport patients but act as first responders) providing initial patient assessment and care. Other collegiate organizations operate as certified ambulance services staffed with EMTs or Paramedics. Some groups limit services to their campus, while others extend services to the surrounding community. Such services include ambulance services, mass-casualty incident response, aero-medical services, and search-and-rescue teams. Fire Service in the US is rated through ISO classes and fire insurance rates (casualty insurance) are based on those classes, EMS does not receive ratings, nor are there corresponding monetary savings in health or life insurance policies. This relegates EMS funding to an emotional plea for funds during difficult financial times.

Professional organizations

 * National Association of Emergency Medical Technicians