- What is EMS?
- Local EMS Agency Functions
- Delivery of EMS Services
- Certification Requirements
- EMS History
What is EMS?
Emergency Medical Services (EMS) is a specially organized system that provides personnel, facilities and equipment for the effective and coordinated delivery of emergency medical services within a geographical area. An effective EMS system involves many different agencies and organizations working together to provide rapid emergency medical response, treatment and transport to those in need of immediate medical attention. Agencies responsible for providing EMS include dispatch centers, public safety agencies, fire departments, ambulance services, hospitals and specialty care centers.
In Pennsylvania, EMS systems are organized on a municipality, county, and/or regional basis. Oversight of the EMS statewide system is through the Pennsylvania Department of Health, Bureau of EMS. Through EMS legislation passed in 1985, PA Act 45/82, and its rules and regulations, today’s EMS system is found throughout all 67 counties in Pennsylvania.
Assisting the PA Department of Health administrate the statewide EMS program are 16 regional EMS councils (EMMCO West being one of these councils) and the state advisory council (PEHSC). Through these councils, funding is provided to EMS providers and stakeholders through a non-tax supported funding mechanism known as the Emergency Medical Service Operation Fund, “EMSOF”. Traffic violation fines are accessed an EMS fee. This funding source supports a significant portion of the $10 million plus annual EMS system costs. Additional funding of the statewide EMS system comes through federal, state, and local grants /funding. EMS departments/agencies rely upon billing for services that are rendered to financially support their organization.
Enacted in 2005 & 2007 are statewide advanced life support (ALS) and basic life support (BLS) treatment protocols. These protocols are the first of their kind in Pennsylvania. All licensed and recognized EMS agencies follow these protocols to render care to ill or injured patients. The protocols are based from national accepted standards and recognized scopes of practices used in today’s emergency medical system.
Augmenting the EMS care practices are specialty trauma care (Trauma Centers) facilities. These trauma centers are accredited through the PA Trauma Systems and range in levels I, II, and III. Level I trauma centers offer a wider range of special trauma services as compared to a Level III trauma center. Statewide treatment protocols enable helicopter and ground ambulances to transport critically injured trauma patients directly to these specialty care trauma centers.
Local EMS Agency Functions
EMS agencies fall into a variety of organizational categories. There is volunteer, volunteer fire department, non-profit, hospital based, municipal, for profit, government, as well as hybrids within each category. And within each of these organizations are different levels of care provided by the EMS agency.
QRS, quick response service, are rapid response agencies that arrive at the scene of an emergency prior to the arrival of transporting ambulances. These first responders provide initial stabilization and care to an injured or ill patient. Police, fire, rescue, industrial, and other public entities provide this essential service. preBLS, basic life support, EMS organizations are staff with at least an EMT and an ambulance attendant. These personnel are trained to stabilize and transport ill or injured patients to acute care facilities. Most of these BLS EMS agencies carry automated external defibrillators (AED) for the immediate treatment of cardiac arrest situations. Some EMS agencies also carry Epie-Pens to stabilize patients suffering an anaphylactic (allergic reaction) situation.
ALS, advanced life support, EMS agencies are staff with at least a paramedic and an EMT. Some are staff with prehospital registered nurses (PHRN) and prehospital physicians. These ALS personnel receive specialty training and have extensive equipment and pharmacological resources to stabilize patients in the prehospital environment.
Aeromedical organizations are staff with medical professionals and paramedics to provide prehospital responses (i.e. car crashes) and Interfacility transports. These aeromedical personnel provide hospital level care through the use specialty care protocols.
Delivery of EMS Services
EMS services are typically provided in response to a medical emergency reported through the 9-1-1 system. A 9-1-1 call placed from any telephone is automatically routed to the appropriate designated Public Safety Answering Point (PSAP). The PSAP dispatches the appropriate personnel to an emergency.
The majority of the county PSAP centers can provide a caller specialized medical assistance through a transfer to a trained Emergency Medical Dispatcher. At this point, the nature of the medical emergency is determined, the call is prioritized as emergent or non-emergent, appropriate personnel and equipment are dispatched and pre-arrival instructions are given, if appropriate. These instructions enable a caller to begin emergency care, prior to the arrival of emergency care personnel.
Emergency medical response areas are determined by local municipalities. PSAP centers are provided primary and secondary EMS agencies to utilize for day to day 911 responses within a municipality. Regional councils, like EMMCO West, work with elected officials and PSAP centers to identify response times, based on population density. Response times are reported to PSAP centers and to EMS agencies to assist them in quality improvement efforts.
Small and large scale incidents are managed by utilization of the incident management system. Police, fire, EMS, EMA, along with other public safety agencies, health, governmental, technical, etc… work jointly to mitigate emergency situations. Within the EMMCO West region, there are 6 EMS organizations that are part of a 150 member statewide EMS striketeam. The regional EMS striketeam has responded to Louisiana and to emergencies within Pennsylvania, included 2 responses within the EMMCO West region.
The NWPAERG (Northwest PA Emergency Response Group) Region #2 area is part of the EMMCO West region. The NWPAERG addresses terrorism and overall emergency preparedness activities for 5 northwestern PA counties. EMMCO West acts as the financial administrator for the NWPAERG and participates with several of the NWPAERG committees to address regional emergency response activities.
The Pennsylvania Department of Health will certify an individual who meets the following qualifications:
Emergency Responder (EMR)
- Meets the age requirement of 16 years of age or older
- Successfully completes a EMR training course approved by the PA Department of Health
- Successfully completes a PA EMR Practical Skills Certification Test
- Successfully completes a PA EMR Written Certification Test
- Certification is valid for a three-year period.
EMR : 50 hours
This is the first level of training that Pennsylvania offers for people who want to be able to help in a medical emergency. This course is designed for those people who may arrive at an emergency scene prior to the arrival of an ambulance. Examples would be industrial response teams, law enforcement personnel, fire fighters, park rangers, ski patrollers or any other rescue organizations.
The course provides knowledge and skills necessary for activating the EMS system and providing immediate care for life threatening illness and injury, controlling the scene and managing the patient until the arrival of an ambulance.
The course includes training in: the roles and responsibilities of the first responder; assessing the patient for injury or illness; cardiopulmonary resuscitation (CPR); control of bleeding and prevention of shock; and airway control and maintenance.
The course includes a Pennsylvania practical skills evaluation and a written examination. Passing both will provide the student with a Pennsylvania State certification as a EMR.
Although EMRs are not able to be the primary care giver on an ambulance, their help as a third caregiver is always greatly appreciated by the ambulance crew.
EMERGENCY MEDICAL TECHNICIAN (EMT)
- Meets the age requirement of 16 years of age or older
- Successfully completes an approved PA Emergency Medical Technician Training Course
- Successfully completes a PA Emergency Medical Technician Practical Skills Test
- Successfully complete a PA Emergency Medical Technician Written Examination
- Certification is valid for a three-year period.
Emergency Medical Technician (EMT): 150-200 hours
The EMT course requires approximately 150-200 hours of instruction that includes the knowledge and skills required to provide basic prehospital emergency care. This program serves as the foundation for emergency medical services.
The course teaches students the overall roles and responsibilities of the EMT; an overview of anatomy and physiology; assessment of injuries and illnesses; cardiopulmonary resuscitation (CPR); control of bleeding and shock; care of muscular skeletal injuries, medical emergencies, childbirth, pediatric emergencies, environmental emergencies; lifting and moving of patients; automatic external defibrillation; and assisting patients with their own prescribed medications. Also included are skills needed to assess the scene, and properly move and transport patients to the emergency department.
The course includes a Pennsylvania State practical skills evaluation and written examination, which, if passed, will provide a PA state certification as an EMT.
Advanced EMT (AEMT)
- Is 18 years of age or older
- Successfully completes and approved PA AEMT course
- An EMS provider education course for EMTs and education, through continuing education courses, in skills required in the scope of practice of an AEMT for with the applicant did not receive education in the AEMT course.
- Successful completion of practical and written PA state certification examinations
- PA AEMT certification is valid for a two-year period.
- Is currently certified as an EMT
- Is 18 years of age or older
- Successfully completes a PA approved Paramedic Training Course
- Successfully completes an Paramedic National Registry Practical Skills Examination
- Successfully completes an the Paramedic National Registry Written Examination
- After successful completion a PA Paramedic Certification will be issued
- PA Paramedic certification is valid for a two-year period.
Prerequisite: Pennsylvania State EMT Certification
The paramedic training program is an extensive and intensive course that significantly increases the knowledge and skills to an advanced level. It includes both clinical and field experiences as well as classroom knowledge and skills. Knowledge and skills include an in-depth review of anatomy and physiology; patient assessment; cardiovascular and respiratory emergencies; pediatric and geriatric emergencies; infectious diseases; fluid and shock therapies; electrocardiogram monitoring and interpretation of cardiac rhythms; Advanced Cardiac Life Support (ACLS) protocols; communications; manual defibrillation and external cardiac pacing; insertion of endotracheal and nasotracheal tubes; intravenous therapy; drug calculations and pharmacology; techniques for administration of emergency medications; performance of cricothyroidotomy and percutaneous transtracheal ventilation; decompression of a tension pneumothorax; and a review of the EMT knowledge and skills.
The course includes the National Registry practical and written examinations.
PRE-HOSPITAL REGISTERED NURSE (PHRN)
- The PA Department of Health will recognize as a pre-hospital registered nurse, a registered nurse who meets the following requirements:
- Verification of PA Licensed RN in good standing
- Current ACLS Card
- 18 years of age or older
- Successfully completes Pennsylvania Pre-hospital Registered Nurse Curriculum adopted by the PA Department of Health or a knowledge and skills assessment process adopted by the PA Department of Health
- Successfully completes the National Registry written PHRN Assessment Test
- Successfully completes the Emergency Medical Technician practical skills examination or
- EMT-Paramedic National Registry Practical Skills Exam
- PA PHRN certification is valid for a two-year period.
PRE-HOSPITAL PHYSICIAN (PHP)
- The PA Department of Health will certify as a Health Professional Physician, a physician approved as having met the requirements of the EMS Act. The physician must be endorsed by the Regional Medical Director and provide the following:
- Verification of a Pennsylvania Physician License
- Copy of current ACLS certification
- Copy of PALS certification
- PA Pre-hospital Physcian certification is valid for a two-year period.
EMT INSTRUCTOR CERTIFICATION
- 18 years of age or older
- Successfully completed an EMS instructor course approved by the Pennsylvania Department of Health or possesses a bachelor’s degree in education or a teacher’s certification in education
- Successfully completed an EMT-Basic Transition program, or update, or has completed an EMT-Basic Course
- Current certification as an EMT or EMT-Paramedic, or Pre-hospital Registered Nurse (PHRN)
- At least one year experience functioning as an EMT, EMT-Paramedic or PHRN providing
- Pre-hospital care
History of the Star of Life
The Star of Life is an easily recognized symbol of EMS. It is seen on the sides of ambulances, on signs directing people to emergency rooms, and on paramedic patches. However, many people, including many EMS people, don’t know the meaning and history of the Star of Life.
Before 1966, it was common for patients to be transported to the hospital in vehicles operated by funeral homes, and few hospitals had doctors trained in emergency medicine. In the late ‘60’s, a study by the National Academy of Sciences was published called Accidental Death and Disability: The Neglected Disease of Modern Society. Dr. Ricardo Martinez, Administrator of the National Highway Traffic Safety Administration (NHTSA) stated in a commemorative edition of this Study: “This paper, known as the ‘White Paper’ revolutionized the way we view and manage injured patients in the United States.” The paper studied auto accidents and the injuries they cause; however, it also studied the “system,” or lack of an emergency medical care system, that was in place at the time. It documented many deficiencies in emergency care. In NHTSA Leading The Way, the White Paper is cited and NHTSA states that many recommendations were made to improve medical response to injuries. It was time to make a change in America and develop a true emergency medical care system.
Carl Post, in his book Omaha Orange – A Popular History of EMS in America, explains how NHTSA, under the Department of Transportation, was tasked with overseeing a program that authorized planning for ambulances and equipment to go in them, after Public Law 89-56 was passed in 1966. Under the Department of Transportation, EMT standards were perfected, paramedic standards were developed, and vehicles were purchased for EMTs and paramedics to use when responding to calls. To easily recognize these emergency care individuals and vehicles, a symbol needed to be designed. It would become known as the “Star of Life.” Arline Zatz wrote about the history of the Star of Life in an article for the July-August 1992 Rescue-EMS Magazine. In the article she indicated that at first, EMS used a red cross with four bars, which is a trademark of the American Red Cross (ARC) and the International Red Cross (ICRC). EMS organizations in the late ‘60’s and early ‘70’s used it or an orange version called Omaha Orange.
Paramedic Mitch Mendler, on the http://www.risherambulance web site, indicated that the ARC did not like EMS using the cross, and the ARC stated it was a violation of an international treaty, backed up by federal law. The treaty and law states that the red cross in any form cannot be used by anyone not connected with the ICRC. Johnson & Johnson is the only corporation that can do this because it was grand fathered under the federal law.
Because the Red Cross symbol could not be used, Leo R. Schwartz, then Chief of the EMS Branch, NHTSA, took the red Medical Identification Symbol (Medic Alert) of the American Medical Association, changed it to blue, and placed it on a white square. This new Star of Life had six bars with a serpent entwined around a staff in the middle. It was registered as a certification mark on February 1, 1977 with the Commissioner of Patents and Trade Marks. The trademark remained in effect for twenty years. In an e-mail discussion, Howard Paul talked about whether a federal agency can obtain copyright protection on things they develop. There has been a lot of controversy over the years about whether anyone could use the Star of Life without DOT permission. However, with or without that protection, this star with the serpent and staff in the middle has become the symbol of emergency medical services.
Meaning of the Six Bars of the Star of Life
The six bars of the Star of Life represent six distinct phases of an EMS response–detection, reporting, response, on scene care, care in transit, and transfer to definitive care. These phases a r e considered critical to producing a good outcome for the patient.
The phases are:
- Detection: Citizens must first recognize that an emergency exists and must know how to contact the EMS system in their community. This can be by several different methods such as dialing 9-1-1, using a seven digit local emergency number, or using amateur radios, or highway call boxes.
- Reporting: Callers are asked specific information so that the proper resources can respond. In an ideal system, certified Emergency Medical Dispatchers (EMDs) ask a predefined set of questions. If someone were having a heart attack, then they would look under the heart attack algorithm for appropriate questions to ask and also give appropriate pre-arrival instructions (such as CPR). In this phase, dispatchers also become a linkbetween the scene and the responding units and can provide additional information as it becomes available.
- Response: This is the response of the EMS resources to the scene. This may be a tiered response with First Responders and EMTs responding initially and backed up by paramedics shortly thereafter (EMS…A System To Save Lives, 2). It may mean that a fire engine and crew are also dispatched to help with lifting and moving the patient or getting them out of a smashed automobile.
- On Scene Care: A lot of types of care can be provided on the scene, versus waiting until the patient arrives at the hospital. Standing orders and radio or cellular contact with the emergency physician has broadened the range of on-scene care that can be provided. A long algorithm of procedures and drugs may be used before the patient is removed from the scene. When the EMS system was just getting started, all patients were transported to a hospital. Today, in certain instances such as cardiac arrest, or when a patient is not seriously ill or injured, not all patients are transported from the scene to a hospital.
- Care in Transit: As stated earlier, patients were once transported in hearses or station wagons, with nobody taking care of them in the back. With the advent of federal regulations and the maturing of EMS, specially designed trucks now carry mobile oxygen, suction, patient monitoring and communications equipment, as well as special drugs for emergency care of patients(EMS…A System To Save Lives , 2). Station wagons and hearses have been replaced with huge 15,000-pound trucks that our EMS personnel call “monster medics.”
- Transfer to Definitive Care: Up until the passage of the Trauma Care Systems Planning and Development Act of 1990, a patient might be seen in the emergency room (ER) by a physician trained in a certain kind of specialty, such as a cardiologist or a surgeon (NHTSA Leading The Way, 7). They usually did not have the training necessary to address the many types of injuries and illnesses that present themselves in an ER. Today, there are board certified emergency medical care physicians waiting to help patients. Nurses now receive certification in emergency care and specialized training in trauma. Hospitals may hold special levels of designation in trauma care. This means they have additional specific equipment, rooms and physicians available for the most traumatically injured patients (NHTSA Leading the Way, 12). There are specialized burn centers to handle burn patients and special children’s hospitals that handle only pediatric patients. Definitive care has come a long way, as has EMS, in a relatively short time. According to Paramedic Mitch Mendler, originally, the Star of Life was supposed to be something different for the different types of EMS personnel. For administrative and dispatch personnel, the Star of Life was to have a silver colored edge and the staff of Aesculapius, a silver colored serpent. For EMT’s and Paramedic’s patches, the edge was supposed to be gold in color with a gold serpent. Jeffrey Linzer indicated in an e-mail message that there is also a version that is supposed to be used to identify receiving facilities, such as hospitals or emergent care facilities [a white star on a blue background].
EMS is a system and the Star of Life represents that system. The system has grown immensely over the past thirty years and will be changing and evolving rapidly in the 21st century. The Ohio state website, Division of EMS, discusses how the EMS system depends on many different elements to make it one of the best in the world. It depends on an informed public being able to recognize when to call for emergency help, the availability of specially trained people and equipment, and a network of specialized trauma centers. The Star of Life symbolizes these elements and, hopefully, once people understand the meaning of the Star, they will understand what actually makes up the EMS system.
History of the Staff of Aesculapius
On a website by the Irish Emergency Ambulance Resources (http//ambulance. eire.org), there is a history of the Staff of Aesculapius. The snake and staff in the center of the symbol portray the staff of Aesculapius who, according to Greek mythology, was the son of Apollo and the mortal maiden Coronis. Apollo was told to instruct his son in the ways of medicine and healing.
Aesculapius became an excellent healer of the sick – too excellent. Zeus, the God of Gods, felt that Aesculapius’ powers were beyond the powers of mortal men and killed him where he stood with a bolt of lightning.
After Aesculapius death, he was worshipped and thought to be a God of healing. People would sleep in his temples. He would appear to them in their dreams offering cures and remedies. Drawings of Aesculapius usually show him in a standing position, dressed in a long cloak, holding a staff with a serpent coiled around it.
Another reason for using the serpent and staff may come from the Bible, in Numbers 21:8 and 9. It makes reference to a serpent on a staff:
And the Lord said unto Moses, Make thee a fiery serpent, and set it upon a pole:
and it shall come to pass, that every one that is bitten, when he looketh upon it, shall live. And Moses made a serpent of brass, and put it upon a pole, and it came to pass, that if a serpent had bitten any man, when he beheld the serpent of brass, he lived.