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Welcome in this part of generalities about ambulances, starlife, emergency numbers, emergency medical services, strategy, training and good samaritan law
Bienvenue dans cette partie de généralités où nous parlerons
d'ambulances, d'étoile de vie, de numéro des secours,
de service de secours médicaux, de stratégies, de formation, ou sur la loi du bon samaritain...
An ambulance is a vehicle designated for the transport of sick or injured people.
The first ambulances called by that name were horse ambulances used in the American Civil War. The first practical ambulances were created by Dominique Jean Larrey, a French surgeon (1766-1842), for use in the Napoleonic Wars.
Modern-day ambulances are typically large automobiles on a van or light truck chassis.
However, an ambulance can be any vehicle, including a bus, helicopter, or even a hospital ship.
During the 1960s and 1970s, station wagons were used in some American cities (despite their limited space) and can be seen in motion pictures from that period.
Under the laws of war, an ambulance marked by a red cross is not to be fired on and is to be permitted to carry out its duties in spite of the fighting. An ambulance may not mount weapons, although the Israeli EMS has produced a "tankbulance" that combines a Merkava main battle tank with ambulance features
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 country-to-country, state-to-state (or province-to-province), and even county-to-county variation of what types of care providers at different levels are allowed to provide. That said:
· Basic Life Support or BLS - usually consists of two EMT-Basics. Provides oxygen therapy, splinting, bleeding control, defibrillation with an AED,and light extrication (eg: removing a victim from a car, but not using the jaws of life.)
· Intermediate Life Support of ILS - usually consists of an EMT-Basic and an EMT-Intermediate. EMT-Intermediates provide BLS care with the addition of IV therapy, and often intubation.
· Advanced Life Support or ALS - usually consists of an EMT-Basic or EMT-Intermediate and a EMT-paramedic. EMT-paramedics provide BLS care and ILS care with the addition of 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.
· Mobile Intensive Care Unit (MICU) - Some services divide ALS, as described above, into units staffed by Intermediates, which they call "ALS units" and units staffed by paramedics, frequently called "MICUs" or "paramedic units." These usually consist of either an EMT and a paramedic or multiple paramedics, and provide the full range of advanced services to include IV therapy, Cardiac monitoring and drugs, pain killers. etc. In some locations, physicians may ride MICUs for special calls or as a matter of course.
· Critical Care Units - consist of a combination of EMTs/Paramedics/Nurses/Physicians depending on the need and service. They may provide special transports for premature babies, cardiac transfers, etc, although in some services, these are standard ALS units.
Need for Flexibility
There is a continuous flux in terms of types of services due to constant efforts to improve efficiency and effectiveness. Indeed, many fire departments are fire-oriented only in name and are becoming all-purpose emergency services organizations.
Ambulances in the United States are usually staffed by at least one EMT driver and one paramedic. Paramedics in the U.S. are professionally trained emergency medical technicians, a healthcare profession distinct from physicians and nurses.
American paramedics called to an emergency will identify and treat anyone needing medical assistance. They stabilize and transport those in need of further medical care to hospitals, calling for additional ambulances as necessary. If the scene is dangerous (because someone is brandishing a gun or a building is on fire) paramedics usually do not enter until police or fire personnel explicitly allow them to do so.
Large American cities like New York and Los Angeles tend to have many distinct ambulance services representing all of the types mentioned above, so pedestrians and drivers must be alert for ambulances of many shapes, sizes, and colors. However, many smaller cities and suburbs are completely dominated by AMR, and AMR vehicles are synonymous with "ambulance" in those areas.
American ambulances usually are fitted with red (and sometimes white, amber and blue) flashing lights and a siren that continuously rises and falls, as opposed to the two or three-tone sirens heard in other countries. When an ambulance turns on its lights and siren, all other drivers are required by law to pull off to the side of the road and yield the right of way.
L’empire Romain fût le premier a disposer d’une organisation permanente de lutte contre l’incendie, divisée en cohortes d’environ 1000 hommes et pour lesquels étaient rattachés 28 médecins (premier exemple de service de santé dans le milieu des secours ).Le terme ambulance provient du latin Ambulans signifiant "qui marche", appliqué au monde des secours, le mot dérive de l'expression militaire "hôpital ambulant" (XVIII-XIXème siècle) et désignait les fameuses infirmerie de campagne du Docteur Larrey.Mais bien avant, on avait utilisé ambulant, tel que celui qui se déplace, au XVII-XVIIIème siècle, c'était les commerçants, les gens du spectacles. La première ambulance à cheval est apparue durant la guerre civile américaine vers 1861, En 1790, en Egypt, "je fis construire cent panier, deux par chameau, disposés en forme de berceau que l'animal portait de chaque côté de sa bosse, suspendus, par les courroies élastiques au moyen d'une prolonge à bascule : ils pouvaient porter un blessé couché dans toute sa longueur" En 1792, M. Larrey (grand théoricien de la logistique de l’avant et Médecin des Armée de l’Empire) imagine le principe d’ambulances volantes à 2 ou à 4 roues constituées d’une équipe de chirurgiens, infirmiers, ainsi que de fourgonde soutien pour le matériel et la réserve, se portant au devant des moribonds pour leurs prodiguer des soins d’urgence et les conditionner en vue d’une évacuation vers l’arrière. En 1871, les oeuvres des ambulances urbaines de l’hôpital St Louis créé la première structure d’assistance médicale d’urgence pour les civils dans laquelle se tiennent prêt à intervenir des médecins et infirmiers avec des voitures hippomobiles.
Ce projet sera abandonné en 1907.
(caisse carrée sur pickup)
(caisse carrée sur van ou camion)
Note that Type I's and Type III's are often called boxes by their crews with Type II's being called vanbulances.
A typical Type II ambulance. Note how, in contrast to the Type III ambulance shown above, the basic shape of this ambulance is that of a standard full-sized van with a raised roof.
Ambulance service providers come in several types in the USA:
1. Volunteer Ambulance Corps (VAC) or services - function similar to Volunteer Fire Companies. St. John Ambulance is the most common, providing world-wide service in locations ranging from New York City to small rural communites, but many VACs are independant corporations. VACs may be community owned or privately owned, but are typically organised as non-profit organizations. VACs may also be part of Volunteer Fire Companies; in some of these cases, EMTs and drivers are also firefighters. Up until recently, Harbor City Volunteer Ambulance Squad (HCVAS) in Melbourne, Florida was the largest volunteer ambulance squad in the United States.
2. Private Ambulance Service - Normal commercial companies with paid employees, of which the largest is AMR (American Medical Response). While many private companies provide inter-facility patient transfer, many communities' 911 needs are served by private services.
3. Municipal Third Service - Operate as a third service alongside fire and police departments. These are more likely to be found in areas with a high population density, such as a city or metropolitan area.
4. Municipal - Usually fire department owned and operated, though some systems are police department owned and operated.
5. Combined - these are full service emergency service agencies such as airport and college public safety offices. Some smaller towns and cities may also have them. Generally all personnel are crosstrained as EMT's/Firefighter/peace officer.
(norme ASSU - aménagement SAMU)
Ambulances in France & Europe
In France, the most general term is "vehicle adapted to patient transport", the term "ambulance" only applies for some categories of patient transport vehicles.
The word "ambulance" is reserved to transportation on medical prescription, including oral prescription in case of emergency. It does not apply to first responders vehicles (most of times firefighters), although they also transport casualties; their vehicles are called VSAV–véhicule de secours et d'assistance aux victimes (rescue and assistance to casualties vehicle), or VPS–véhicules de premiers secours (first responders vehicles) in case of volunteers from associations. The VSAV and VPS are considered as vectors that bring rescue workers and devices onsite, the evacuation being only the logical following of this intervention but not their main duty.
There are therefore two kinds of ambulance providers: hospitals and private companies.
The reglementation classifies the patient transport vehicles in four types:
· A-type : ambulance for rescue and emergency care (ambulance de secours et de soins d'urgence–Assu) : in these ambulances, the personnel can stand; only these vehicles can be used for emergency (sanitary duty and H-MICU, see below) ;
· B-type : rescue and assistance to casualty vehicles (VSAV), i.e. first responders vehicles, very close to the A-type ;
· C-type : ambulance : the personnel cannot stand, it only allows the transport of a lying patient and of a sitting ambulance technician besides ; due to the lack of room, cares cannot be performed during the transport (these vehicles tend to disappear) ;
· D -type: light vehicle (véhicule sanitaire léger–VSL) : normal car without any specific equipment, for patient who can sit.
The A, B and C-types are called "specially equipped" vehicles, and must follow the NF EN 1789 standard (December 1999).
First responders vehicles
A VSAV has three professional1 CFR onboard, a VPS has five volunteer CFR.
The first responders of the VSAV and VPS are called secouristes and have 60 hours of initial education (plus additional continuous education) and perform non-medical, non-invasive acts. They use splints (including cervical collars, long spine boards and vacuum mattresses), oxygen first aid, and make the casualty lifting.
There are two kind of hospital ambulances:
· internal ambulances, which drive the patients from a building to the other; these are sometimes simple vehicles without any medical equipment when the transport do not require any care (these are always very short transportations).
· the UMH–unité mobile hospitalière (H-MICU–hospital medical intensive care unit) from the SMURr–service mobile d'urgence et de réanimation (mobile emergency resuscitation service) : an ambulance with an MD, a nurse and an ambulance technician that do pre-hospital intervention and interhospital transportation under intensive care.
The H-MICU is often a light rapid-intervention vehicle, i.e. a car carrying the personnel and the material to the casualty; the transport itself is made with a VSAV or a private ambulance equipped with the medical unit.
Special warning devices and traffic law
The H-MICU (A-type) and VSAV (B-type) have a blue rotating light and a two-tones siren (high-low-high-low-high-low...). When these special warning devices are on and when the emergency of the mission justifies it and as long as they do not endanger the life of other people, the traffic law allow them to get rid of certain limitations such as speed limits, direction of driving, priorities and traffic light. In most states, this allows ambulances to travel no more than 5 miles per hour above the posted speed limit. Also, when approaching a red light, the ambulance must first stop, determine the intersection is clear, and then may proceed regardless of what color the light is.
The ambulance of private companies (A- and C-type) have a blue flashing light and a three-tones siren (high-low-high...high-low-high...). When these special warning devices are on and when the emergency of the mission justifies it and as long as they do not endanger the life of other people, traffic laws allow them to get rid of certain limitations such as speed limits while respecting lane priorities and traffic lights.
FEUX A ECLATS
Pour écouter:/ to listen ITALY,
RDV sur www.codice-3.org/an_francoise.html,
et pour / and for SPAIN,
RDV sur www.la-ambulancia-azul.es/
Do you know ANDY & his friends, no ???
why don't you meet them...
Also you can see here OLD AMBULANCES
I have a few ambulances pictures that i don't know origins, so if you want to look at them, may be you'll be able to help me .... HERE
What is an ERV, part of many special vehicles??
More on ambulance history.....
Dessiné et géré par le National Highway Traffic Safety Administration (USA - ministère des transports -1966) est en charge des normes de sécurité automobile et de la surveillance du respect par les constructeurs de ces directives, et dont l'une des missions originelle était d'établir les normes des EMS.
La création de ce sigle a suivi une plainte de la Croix-rouge concernant l'utilisation abusive et désordonnée de son emblème. Cette plainte concernait entre autre l'utilisation d'une croix-rouge dans un triangle orange
The Star of Life is a blue, six-pointed star with the Rod of Asclepius in the center, originally designed and governed by the NHTSA. Internationally, it designates emergency care units and personnel.
A similar orange star is used for search and rescue personnel.
The Star was created in 1973 by Leo R. Schwartz, Chief of the EMS branch at the NHTSA to avoid juridic problems related to the use of derivatives of the Red Cross (like orange cross, green cross, etc.). The Star of Life was registered as a certification mark on February 1, 1977.
The six branches of the star are symbols of the six main tasks executed by rescuers all through the emergency chain:
1. The first rescuers on the scene observe the scene, understand the problem, identify the dangers to themselves and the patient(s), and take appropriate measures to ensure the safety on the scene (circulation, electricity, chemicals, radiations, etc.).
2. The first rescuers call for professional help.
3. The first rescuers provide first aid and immediate care to the extent of their capabilities.
4. The EMS personnel arrive and provide immediate care to the extent of their capabilities.
5. The EMS personnel proceed to transfer the patient to a hospital for specialised care. They provide medical care during the transportation.
6. Appropriate specialized care is provided at the hospital
The National Highway Traffic Safety Administration (NHTSA, often pronounced "nit-suh") is a U.S. Government agency, part of the Department of Transportation, responsible for setting safety standards and verifying compliance by automobile manufacturers. It also issues guidelines for consumers, and publishes the results of safety tests of various automobiles, to allow buyers to evaluate the anticipated behavior of an automobile in a crash.
In 1965 and 1966, public pressure grew to increase safety of cars, culminating with the publishing of Ralph Nader's book Unsafe at Any Speed, and National Academy of Sciences' "Accidental Death and Disability - The Neglected Disease of Modern Society". In 1966, congress held a series of highly publicized hearings regarding highway safety, and passed legislation to make installation of seat belts mandatory, and created several predacessor agencies which would eventually become the NHTSA, including the National Traffic Safety Agency, the National Highway Safety Agency, and the National Highway Safety Bureau.
The NHTSA was officially established in 1970 by the Highway Safety Act of 1970. In 1972, the Motor Vehicle Information and Cost Savings Act expanded NHTSA's scope to include consumer information programs.
La star life est une étoile bleue dotée de 6 branches dont les significations nous rappelle...
Le sauveteur observe, comprend le problème, identifie les dangers, et met en place les protections
aide appropriée à l'hôpital
le sauveteur appelle les secouristes
les secouristes transferts le patient à l'hôpital
le sauveteur produit les premiers secours pour éviter l'aggravation
Les secouristes arrivent et prodiguent les soins avancés
Plus d'info ...
More on ... STATION 15 (South Africa)
or on (great belgian site)
Rod of Asclepius
Symbole de l'ancien grecque associé à la médecine. Asclepius, fils d'Apollon est un héros qui deviendra dieu de la médecine.
Le centaur Chiron, son mentor et tuteur lui enseignera la guérison.
Il deviendra le symbole des EMS.
Originellement, il s'agit du symbole du commerce, il appartenait à Hermès, qui l'échangea avec Apollon contre une lyre.
Il deviendra le symbole de la médecine.
...D'EMERGENCY PHONE NUMBER
Le premier numéro d'appel des secours est celui mis en place à Londres en 1937, le 999 .
Aux états unis, c'est en 1959 qu'apparaît le premier numéro d'appel alors que le 911 n'est apparu en Alabama qu'en 1968, et est généralisé dans les années 70.
En France, c'est en 1929, qu'apparaît la connexion automatique avec le 18, le 15 n'apparaît qu'en 1978.
Le 112 a été proposé par le Conférence Européenne des administrations des Postes et Télécommunications en 1972 mais n'a été utilisé qu'en 1991 après accord du conseil des communautés européennes.
Ce numéro n'est opérationnel dans toute l'Europe que depuis 2000 en raison de divers problèmes techniques (en France par exemple, il y avait incompatibilité avec l'annuaire, le 11)
Le 112 est gratuit, disponible de tous les pays Européen, et interconnectés entre les différents services ( police - fire - ambulance), certains pays ont gardés leurs anciens numéros et le 112, d'autres n'ont gardé que le 112.
Garder le numéro secours médical, ou police ou pompiers propre à un pays en plus du 112 permet aux étrangers d'appeler sans problèmes les secours mais aussi aux locaux de gagner du temps en évitant d'en perdre en passant par une centrale pallier supplémentaire et donc perdre de temps....pense t'il, qu'en est il ?
The first emergency number system to be deployed was in London, United Kingdom on June 30, 1937. When 999 was dialed, a buzzer sounded and a red light flashed in the exchange to attract an operator's attention. It was gradually extended to cover the entire country, but it was not until the late 1960s that the facility was available from every telephone.
In the days of loop disconnect dialing, attention was devoted to making the numbers difficult to dial accidentally by making them involve long sequences of pulses, such as with the UK 999 emergency number. This contrasts to modern times, where repeated sequences of numbers are easily dialed on mobile phones, particularly as mobile phones will dial an emergency number while the keypad is locked or even without a SIM card. Some people in the UK have reported accidentally dialing 112 by loop-disconnect while working on extension telephone wiring, and point to this as a disadvantage of that number.
The first North American emergency number was the 999 system deployed in Winnipeg, Manitoba, Canada in 1959 at the urging of Stephen Juba, mayor of Winnipeg at the time. The first US911 emergency phone system was set up in Alabama in 1968, but it was not in use everywhere until the 1970s. To standardize the number across most of the NANP, Canada switched to using 911 as its emergency number in 1972. (Some Caribbean islands use 999.)
In France, in 1928, telephone operators had to connect the calls for emergency reasons even when the phone service was closed. In 1929, an automatic connection system is set up, initially for less than 10,000 people in Paris, allowing them to dial 18 to reach the fire brigade. The service was not widespread until the 1970s.
The CEPT recommended the use of 112 in 1972. The European Union subsequently adopted the 112 number as a standard on 29 July1991. It is now a valid emergency number throughout EU countries and in many other CEPT countries. It sometimes works in parallel with other emergency numbers in countries such as Britain and Ireland.
Emergency numbers and mobile/wireless/cellular telephones
The GSM mobile phone standard includes 112 as an emergency number, no matter what other local emergency number are applicable. This is valuable for foreign travelers, who may not know a local one.
Using 112 instead of another emergency number on a GSM phone may be advantageous, since 112 is recognized by all GSM phones as an emergency number. A phone dialing a different emergency services number may refuse to roam onto another network, leading to trouble if there is no access to the home network. Dialing 112 forces the phone to make the call on any network possible. However, some GSM networks (e.g. in Belgium, Spain, UK, Liechtenstein) are reported to connect emergency calls only from phones with a valid account on their network, e.g. customers and roamers only. Some GSM networks will not accept emergency calls from phones without a SIM card, or a SIM card without credit.
In the United States, the FCC requires networks to route every mobile-phone 911 call to an emergency service call center, including phones that have never had service, or whose service has lapsed. As a result, there are programs that provide donated used mobile phones to victims of domestic violence and others especially likely to need emergency services.
Mobile phones generate additional problems for emergency operators, as many phones will allow emergency numbers to be dialed even while the keypad is locked. Since mobile phones are typically carried in pockets and small bags, the keys can easily be depressed accidentally, leading to unintended calls. A system has been developed in the UK which connects calls where the caller is silent to an automated system, leaving operators more free to handle genuine emergency calls.
999 is Ireland's and the United Kingdom's emergency telephone number along with the EU standard 112. Either number can be used but 999 is more popular and better-known than 112. It is also the emergency telephone number in some Commonwealth countries. It is also used in the Ghana, The United Arab Emirates, Hong Kong, Macau, Malaysia and Singapore.
It is an all-service number, meaning that it should be called in any situations where state-run emergency services are needed. The three main and best-known services are fire brigade, police and ambulance. Other available services include coastguards, mountain rescue and cave rescue (where locally relevant). Some situations such as a major car accident or a terrorist attack (including nuclear, biological, or chemical attacks) will require multiple and/or specialist services but the first point of call for reporting such incidents from the general public is still the 999 system. In some situations there will be specific instructions on nearby signs to notify some other authority of an emergency before calling 999. For example there are notices on bridges carrying railways over roads telling people that, if they see a road vehicle striking the bridge, they should call the railway authority (on a given number) first and then call 999 to inform the police.
In the UK, the number is operated by BT and Cable and Wireless for the Home Office.
The 999 service was introduced on 30 June1937 in the London area. 999 was chosen because of the need for the code to be able to be dialled from payphones - the old A/B button payphones. The telephone dial (GPO Dial No 11) used with these coinboxes allowed the digit '0' to be dialled without inserting any money. It was very easy to adapt the dial also a digit '9' without inserting money. All other digits from 2 to 8 were in use somewhere in the UK as the initial digits for subscribers telephone numbers and hence could not easily be used. Also had any other digits been used, other digits between that one and the already free '0' would also have been able to be dialled for free. Also no other 'subscribers' telephone numbers existed using combinations of the digits '9' & '0' - other than one in Woolwich - therefore there would be no other unauthorised 'free' calls. Thus the easy conversion of coinbox dial was the deciding factor and the fact that 999 was not used anywhere - other than for accessing the odd 'position 9' of a Engineering Test Desk in the telephone exchange - codes 991 upwards accesed the individual Test Desk postions.
The 'pan European' 112 code was introduced in the UK by BT in December 1992, with little publicity. It connects to existing 999 circuits.
On 6 October1998, BT introduced a new system whereby all the information about the location of the calling telephone was transmitted electronically to the relevant service rather than reading it out audibly (with the possibility of errors)
000 (sometimes known as triple-O) is the primary national emergency number in Australia. It is operated by Telstra Corporation Limited as a condition of its telecommunications licence, and is intended only for use in life-threatening emergencies. Other emergency numbers in Australia are 112 for GSMmobile phones—which is redirected to a 000 operator—and 106 for textphones.
Prior to 1961, Australia had no national number for emergency services; the police, fire and ambulance services possessed many phone numbers, one for each local unit. In 1961, Telecom introduced the 000 number in major population centres and near the end of the 1980s extended its coverage to nationwide. The number 000 was chosen for several reasons, one of which was that zero was closest to the finger stall on rotary dial phones, so it was easy to dial in darkness.
As the Australian Communications and Media Authority does not regard State Emergency Service (SES) calls as life-threatening, the 000 number does not allow them to be contacted. Asking for the SES prompts a recorded announcement explaining how to proceed.
On December 3, 2003, floods and storms in Melbourne caused a large influx of 000 calls, preventing some calls from being answered immediately: this caused some users interviewed by authorities to believe that they had dialled the wrong number. A subsequent investigation recommended that a recorded announcement be set up to assure callers that their calls were being connected.
Development of 9-1-1
The push for the development of a nationwide emergency telephone number came in 1957 when the National Association of Fire Chiefs recommended a single number to be used for reporting fires. In 1967 the President's Commission on Law Enforcement and Administration of Justice recommended the creation of a single number that can be used nationwide for reporting emergencies. The burden then fell on the Federal Communication Commission, which then met with AT&T in November 1967 in order to come up with a solution.
In 1968, a solution was agreed upon. AT&T had chosen the number 911, which met the requirements that it be brief, easy to remember, dialed easily, and that it worked well with the phone systems in place at the time. How the number 911 itself was chosen is not well known and is subject to much speculation. However, many feel that the number 911 was chosen to be similar to the numbers 2-1-1 (long distance), 4-1-1 (information, later called "directory assistance"), and 6-1-1 (repair service), which had already been in use by AT&T since 1966.
Furthermore, the North American Numbering Plan in use at the time established rules for which numbers can be used for area codes and exchanges. At the time, the middle digit of an area code had to be either a 0 or 1, and the first two digits of an exchange could not be a 1. At the telephone switching station, the second dialed digit was used to determine if the number was long distance or local. If the number had a 0 or 1 as the second digit, it was long distance, and it was a local call if it was any other number. Thus, since the number 911 was detected by the switching equipment as a special number, it could be routed appropriately. Also, since 911 was a unique number, never having been used as an area code or service code (although at one point GTE used test numbers such as 11911), it fit into the phone system easily.
Just 35 days after AT&T's announcement of 9-1-1 as their choice of the three-digit emergency number, on February 16, 1968, the first-ever 9-1-1 call was placed by Alabama Speaker of the House Rankin Fite from Haleyville, Alabama City Hall to U.S. Rep. Tom Bevill (Dem.) at the city's police station. Bevill reportedly answered the phone with "Hello." Attending with Fite was Haleyville mayor James Whitt. At the police station with Bevill was Gallagher and Alabama Public Service Commission director Eugene "Bull" Connor (formerly the Birmingham police chief involved in federal desegregation). Fitzgerald was at the ATC central office serving Haleyville, and actually observed the call pass through the switching gear, as the mechanical equipment clunked out "9-1-1." The phone used to answer the first 911 call, a bright red model, is now in a museum in Haleyville, while a duplicate phone is still in use at the police station. Some accounts of the event claim that, "Later, the two (Bevill and Fite) said they exchanged greetings, hung up and 'had coffee and doughnuts.'"
In 1973, the White House urged nationwide adoption of 911. In1999, President Bill Clinton signed the bill that designated 911 as the nationwide emergency number. Even though 9-1-1 was introduced in 1968, the network did not completely cover the United States and Canada until the late 1990s.
Funding of 9-1-1
9-1-1 and enhanced 9-1-1 are typically funded pursuant to state laws that impose monthly fees on local and wireless telephone customers. Depending on the state, counties and cities may also levy a fee, which may be in addition to, or in lieu of, the state fee. The fees are collected by local exchange and wireless carriers through monthly surcharges on customer telephone bills. The collected fees are remitted to 911 administrative bodies, which may be a statewide 911 board, the state public utility commission, a state revenue department, or local 911 agencies. These agencies disburse the funds to the Public Safety Answering Points for 911 purposes as specified in the various statutes. Telephone companies, including wireless carriers, may be entitled to apply for and receive reimbursements for costs of compliance with federal and state laws requiring that their networks be compatible with 9-1-1 and enhanced 9-1-1.
The amount of the fees vary widely by state and locality. Fees may range from around $.25 per month to $3.00 per month per line. The average wireless 9-1-1 fee is around $.72. Since the monthly fees do not vary by the customer's usage of the network, the fees are considered, in tax terms, as highly "regressive", i.e., the fees disproportionately burden low-volume users of the public switched network (PSN) as compared with high-volume users. Some states cap the number of lines subject to the fee for large multi-line businesses, thereby shifting more of the fee burden to low-volume single-line residential customers or wireless customers.
Congress in 2004 authorized $250,000,000 in annual funding for the 9-1-1 program, but actual appropriations to state and local 9-1-1 agencies are yet to occur.
Locating callers automatically
In over 93% of locations in the United States and Canada, dialing "911" from any telephone will link the caller to an emergencydispatch center—called a PSAP, or Public Safety Answering Point, by the telecom industry—which can send emergency responders to the caller's location in an emergency. In some areas enhanced 911 is available, which automatically gives dispatch the caller's location, if available.
Dialing 9-1-1 from a mobile phone (Celluar/PCS) in the United States originally reached the state police or highway patrol, instead of the local public safety answering point (PSAP). The caller had to describe his/her exact location so that the agency could transfer the call to the correct local emergency services. This happens because the exact location of the cellular phone isn't normally transmitted with the voice call.
In 2000 the FCC issued an Order requiring wireless carriers to determine and transmit the location of callers who dial 9-1-1. They set up a phased program: Phase I transmitted the location of the receiving antenna for 9-1-1 calls, while Phase II transmitted the location of the calling telephone. The Order set up certain accuracy requirements and other technical details, and milestones for completing the implementation of wireless location services. Subsequent to the FCC's Order, many wireless carriers requested waivers of the milestones, and the FCC granted many of them. As of mid-2005, the process of Phase II implementation is generally underway, but limited by the complexity of coordination equired between wireless carriers, PSAPs, local telephone companies and other affected government agencies, and the limited funding available to local agencies for the conversion of PSAP equipment to display the location data (usually on computerized maps).
These FCC rules require new mobile phones to provide their latitude and longitude to emergency operators in the event of a 911 call. Carriers may choose whether to implement this via GPSchips in each phone, or via triangulation between cell towers. In addition, the rules require carriers to connect 911 calls from any mobile phone, regardless of whether that phone is currently active. Due to limitations in technology (of the mobile phone, cell phone towers, and PSAP equipment), a mobile callers' geographical information may not always be available to the local PSAP. Although there are other ways, in addition to those previously stated, in which to obtain the geographical location of the caller, the caller should try to be aware of the location of the incident for which they are calling.
In the U.S., FCC rules require every telephone that can physically access the network to be able to dial 911, regardless of any reason that normal service may have been disconnected (including non-payment). On wired (land line) phones, this usually is accomplished by a "soft" dial tone, which sounds normal, but will only allow emergency calls. Often, an unused and unpublished phone number will be issued to the line so that it will work properly.
If 911 is dialed from a commercial VoIP service, depending on how the provider handles such calls, the call may not go anywhere at all, or it may go to a non-emergency number at the public safety answering point associated with the billing or service address of the caller. Because a VoIP adapter can be plugged into any broadband internet connection, the caller could actually be hundreds or even thousands of miles away from home, yet if the call goes to an answering point at all, it would be the one associated with the aller's address and not the actual location. It may never be possible to accurately pinpoint the exact location of a VoIP user (even if a GPS receiver is installed in the VoIP adapter, it will likely be indoors, and may not be able to get a signal), so users should be aware of this limitation and make other arrangements for summoning assistance in an emergency.
In March 2005, commercial Internet telephony provider Vonage was sued by the Texas attorney general, who alleged that their website and other sales and service documentation did not make clear enough that Vonage's provision of 911 service was not done in the traditional manner.
In May 2005 the FCC issued an Order requiring VoIP providers to offer 9-1-1 service to all their subscribers within 120 days of the Order being published. The Order as set off anxiety among many VoIP providers, who feel it will be too expensive and require them to adopt solutions that won't support future VoIP products.
There are some problems with the assignment of the number 9-1- 1. In particular, it can cause some dialing-pattern problems in hotels and businesses. Some hotels, for example, have been known to require dialling "91+" to make an outside call. This leads to calls that look like 91+1+301+555+2368. Since that's a valid number, which starts with 911, and is not a call to an emergency service, a timeout becomes necessary on actual calls to 911. Such prefixes are strongly discouraged by telephone companies. This is also part of the reason why no area codes start with a "1": the slightly less troublesome "outside line" prefix of "9+" would then cause the same problem: "9+114+555+2368", for example. Another possible problem is that the international phone code for India is "91", and sometimes calls meant for India end up at the local emergency dispatch office. And in Germany, the domestic area code "0911" is reserved for the town of Nürnberg (Nuremberg) - in European countries with an open telephone numbering plan, like Germany, all area codes begin with a "0" prefix.
The number's close association with emergencies has led to "911" being used as shorthand for "emergency" in text messages sent to pagers and mobile phones—however, this is often used to tag situations which do not have the life-safety implications that an actual call to 911 implies.
Emergency numbers outside the U.S. & Canada
Additionally, 9-1-1 is used so pervasively in U.S. and Canadian media and safetyeducation that other countries have sometimes had difficulty in educating children not to dial 9-1-1 for help at all. Even many American tourists do not know that 9-1-1 is not generally an emergency number outside the U.S. and Canada, and sometimes face problems when they are abroad.
The Netherlands, however, has redirected 9-1-1 to the local emergency line, 1-1-2.
The most common emergency number outside the U.S. and Canada is 1-1-2. The next most common is 9-9-9. Germany, for example, also uses 1-1-0 for police and
1-1-2 for fire & ambulance.
In 1991, the European Union established
1-1-2 as the universal emergency number for all its member states. In most E.U. countries, 1-1-2 is already effective and can be called toll-free from any telephone or any cellphone. The GSM mobile phone standard designates 1-1-2 as an emergency number, so it will work on such systems even in the U.S. In the UK, the number is 9-9-9 with 1-1-2 working in parallel.
In New Zealand, because rotary telephone dials were scribed in the reverse order of ones in the UK (0-9, instead of 9-0), 1-1-1 was selected as the emergency number.
A list of Emergency telephone numbers around the world can be found here.
9-1-1 Emergency Telephone Number Day
9-1-1 Emergency Telephone Number Day was proclaimed, by President Reagan in 1987, to occur on the 11th day of September, the ninth month, of that year. The proclamation was made to promote the North American universal emergency telephone number 9-1-1.
Until 2001, September 11 was celebrated by many United States communities as "9-1-1 emergency number day" or simply "911 day". The promotional effort was often led by firefighters and the police. After the September 11, 2001 attacks, the reminders of 9-1-1 were merged with or dropped in favor of remembrance of the attacks.
When the 9-1-1 system was originally introduced, it was advertised as the "nine-eleven" service. This was changed when some panicked individuals tried to find the
"eleven" key on their telephones (this may seem bizarre and amusing, but it is important to remember that in emergencies people can easily become extremely confused and irrational). Therefore, all references to the telephone number 9-1-1 are now always made as nine-one-one — never as "nine-eleven."
Some newspapers and other media require that references to the phone number be ormatted as 9-1-1; nine-eleven is still used occasionally but less so since the term came to refer to the September 11 attacks in the United States, as Americans write dates month/day (unlike Europeans, who write dates day/month).
Emergency telephone number
Many countries' public telephone networks have a single emergency telephone number, sometimes known as the universal emergency telephone number or occasionally the emergency services number, that allows a caller to contact local emergency services for assistance. The emergency telephone number may differ from country to country. It is typically a three-digit number so that it can be easily remembered and dialed quickly. Some countries have a different emergency
number for each of the different emergency services; these often differ only by the last digit.
Use of emergency numbers
The number is intended to be used only in an emergency.
For routine and non-urgent enquiries emergency services generally provide traditional telephone numbers for contact. These are normally listed in the local telephone directory. In the United Kingdom, for example, the number 0845 46 47 can also be dialled for NHS Direct, a non-emergency medical service. Routine and non-urgent calls as well as hoax or prank calls to emergency services numbers waste the time of both dispatchers and emergency responders and can endanger lives. False reports of emergencies are often prosecuted as crimes.
In the North American Numbering Plan, 3-1-1 is the new urgent telephone number, that can be used to contact the police and other services to report minor incidents and historic crime that does not endanger life, to avoid overloading 9-1-1. Some cities also use 3-1-1 for contacting other municipalgovernment services, or to report situations like power outages.
The telephone number 1-1-2 is the international emergency telephone number for GSMmobile phone networks. It does not necessarily work on other mobile phone technologies. In all EU (European Union) countries it is also the emergency telephone number for both mobile and fixed-line telephones. 
In countries where 1-1-2 is not the standard emergency telephone number, GSM telephone users who make calls to 1-1-2 generally have their calls redirected to the local emergency telephone number, if it exists. GSM telephone users in this situation should contact their service provider for emergency information applicable to their service. Most GSM mobile phones can dial 1-1-2 calls even when the phone keyboard is locked.
Configuration and operation
The emergency telephone number is a special case in the country's telephone number plan. In the past, calls to the emergency telephone number were often routed over special dedicated circuits. Though with the advent of electronic exchanges these calls are now often mixed with ordinary telephone traffic, they still may be able to access circuits that other traffic cannot. Often the system is set up so that once a call is made to an emergency telephone number, it must be answered. Should the caller abandon the call, the line may still be held until the emergency service answers and releases the call.
An emergency telephone number call may be answered by either a telephone operator or an emergency service dispatcher. The nature of the emergency (police, fire, medical) is then determined. If the call has been answered by a telephone operator, they then connect the call to the appropriate emergency service, who then dispatches the appropriate help. In the case of multiple services being needed on a call, the most urgent need must be determined, with other services being called in as needed.
Emergency dispatchers are trained to control the call in order to provide help in an appropriate manner. The emergency dispatcher may find it necessary to give urgent advice in life-threatening situations. Some dispatchers have special training in telling people how to perform first aid or CPR.
In many parts of the world, an emergency service can identify the telephone number that a call has been placed from. This is normally done using the system that the telephone company uses to bill calls, making the number visible even for users who have unlisted numbers or who block caller ID. For an individual fixed landline telephone, the caller's number can often be associated with the caller's address and therefore their location. However, with mobile phones and business telephones, the address may be a mailing address rather than the caller's location. The latest "enhanced" systems, such as Enhanced 911, are able to provide the physical location of mobile telephones. This is often specifically mandated in a country's legislation.
Australia: 000 On a mobile phone, dial 112 or 000, remembering to tell the operator what state you are in. If you have a textphone/TTY, you can use the National Relay Service on 106. SES units in Victoria, New South Wales and South Australia can be contacted on 132 500. In Western Australia, the number is 1300 130 039. In the ACT, the number is 6207 8455. In Queensland, Tasmania and Northern Territory, you will have to call the individual units.
....D'EMERGENCY MÉDICAL SERVICE
The Emergency Medical Service system (known by the acronym "EMS" in the USA and Canada) is responsible for providing pre-hospital (or out-of-hospital) care by paramedics, emergency medical technicians (EMT's), and Medical first responders (MFRs in US terminology). The goal of EMS is to provide early treatment to those in need of urgent medical care, and ultimately rapid transportation to an Emergency department. Stabilizing a patient early (within the golden hour significantly increases their chances of survivial, particularly in the event of a heart attack, diabetic emergency, or severe physical trauma).
EMS providers work under the license 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 care.
EMS professionals are trained to follow a formal and carefully designed decision tree, more commonly referred to as a protocol or standard of care, which has been created and approved by physicians. The emphasis in emergency services is on following correct procedure quickly and accurately rather than on making in-depth diagnoses that require much professional training and experience. The use of a decision tree allows EMS workers to be trained in a much shorter time than physicians, with EMT-Basic classes, for example, as short as 1-5 months. Paramedic training is the highest level of EMT, and allows advanced airway skills including airway tube placement, emergency creation of an airway
( crichothyrotomy), cardiac monitoring, intravenous cannulation and Advanced Cardiac Life Support.
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.
The origins of EMS date back to the days of Napoleon, when the French army utilized horse drawn "ambulances" to transport the injured soldier from the battlefield. One of the first civilian EMS services can be traced back to 1869, when Dr. Edward L. Dalton at Bellevue Hospital, then known as the Free Hospital of New York, in New York City started a basic transportation service for the sick and injured. The component of care on scene began in 1928, when Julien Stanley Wise started the Roanoke Life Saving and First Aid Crew in Roanoke, Virginia, which was the first land-based rescue squad in the nation. Over the years EMS continued to evolve into much more than a "ride to the hospital."
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 (see paramedic). 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 advisor 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.
Many EMS units are typically the same as a First Aid, Rescue, EMS, Emergency or Safety Squad. However, a Rescue Squad may also rarely be part of a Fire Department, race car team, or military unit. In the traditional sense, dating back to the early 1900's, a Rescue Squad is a volunteer organization that provides Emergency Medical Services as part of the rescue operation which includes but is not limited to confined space, cave, motor vehicle extrication, search and rescue, high angle, water rescue, mountain/ski rescue and so on. As many Fire Departments only recently during the 1990's have taken over rescue, many squads that used to function as "true" Rescue Squads have recently only been relegated to basic EMS Ambulance services. However, a large majority of Rescue Squads still maintain and perform their original and historical function of Emergency Medical Services as part of a rescue operation such as Motor Vehicle Extrication, Search, or any of the other aforementioned rescue operations. Typically, a Rescue Squad has equipment such as ambulances, light and heavy rescue vehicles, boats, and other rescue equipment, and staffs their rescue department with EMT's who understand patient care in a rescue situation. A prime example would be an organization such as the Pittsburgh EMS http://www.city.pittsburgh.pa.us/ems/
SAMU (Service d'Aide Médicale d'Urgence, "Emergency Medical Assistance Service") is the French hospital based emergency medical service. It was founded in 1968 by coordinating the existing SMUR teams (prehospital care units).
The name SAMU is also used by several French-speaking countries as well as Spanish-speaking countries such as Argentina; it then stands for Sistemas de Atencion Médica de Urgencias y Emergencias (sometimes SAME).
SAMU missions are defined in a law of 1986. SAMU are defined as hospital services providing permanent phone support, choosing and dispatching the proper response for the call in the swiftest delays. These responses can range from
• Medical advices (28% of the calls)
• Sending ambulances, from the fire department for street accident or disease or absolute emergencies at home (24% of the calls), or from private companies for relative emergency transportation from home (8% of the calls)
• Sending a generalist physician at home (22% of the calls)
• Sending a ressuscitation ambulance (H-MICU: hospital mobile intensive ressuscitation unit, called UMH-Unité Mobile Hospitalière), fast intervention vehicle or medical helicopter for the most serious cases
• Management of crisis with large numbers of casualties (plan rouge, plan blanc), they maintain the mobile sanitary kits (postes sanitaires mobiles, PSM).
The French philosophy for medical emergencies allows the reanimation units to be dispatched only in life-threatening cases.
SAMU are also in charge for the training of emergency physicians.
All French Départements hold one SAMU (that is roughly one for 500 000 people), which makes a total of a hundred units, and 350 SMUR in the whole France.
Additionally, two SAMU have special tasks :
• The SAMU de Paris is in charge for emergencies in fast trains (TGV) and flying Air France aircraft.
• The SAMU de Toulouse is in charge for ships at sea.
The main component of the SAMU is the dispatch, called Centre 15 (15 is the emergency number for medical emergency) or CRRA (centre de réception et de régulation des appels: calls reception and dispatch center). The CRRA received about 10 million calls in 2004, with a regular increase of 10% per year:
• 57% from individuals (witnesses or victims of an accident or disease);
• 27% from the firefighters (NB: in France, firefighters are in charge of emergency ambulances, as certified first responders)
• 5% from the hospitals (usually life threatening emergencies in a department)
• 5% from a general practitioner (usually visiting a patient at home)
• 5% rest (police, ambulance - in France, private ambulance society mainly act as transport for programmed acts, a kind of paramedical taxi).
Prehospital Care Strategy
The French doctrine relies on the hopes of survival for a critically injured patient decreasing exponentially with time, which explains why so many patients die during transportation. To maximise the chances of recovery, it is believed important to cut down on tansportation time, and bring a fully equipied and qualified team to the patient, rather than sending an ambulance to pick up the patient and double the travel back to hospital. To this effect, Mobile Emergency Units (SMUR) are equipped with both a fully qualified emergency physician and medical equipment.
This doctrine also simplifies greatly the Emergency department of hospitals (eliminating the need for a "smaller hospital within the hospital"), and ensure that the stabilised patient will receive care from a specialist rather than an emergency generalist.
In extreme cases, heart operations have been performed on the street (resulting in surviving patients). Overall, the French SAMU is arguably one of the very best in the world, innovating in lots of areas (the French SAMU are the only emergency teams to have tested portable succion cardiopumps on scene) and inspiring equivalent services in other countries.
The French emergency system is very different from emergency systems from the USA and the United Kingdom, for instance : one notable difference is that intervention units (ambulance or SMUR) may decide to stay on the scene for a long time (much more than the typical 10 minutes that ambulances spend on a scene before picking up a patient in most other countries).
This is often described as stay and play, opposed to the scoop and run strategy performed in the United States and in the United Kingdom. This is not totally true as in most cases, the patient is at the hospital within the golden hour, the best description would be play and run.
This feature is often misunderstood among the American public or British public. For instance, when Diana, Princess of Wales died in Paris, some British tabloids took outrage that the patient had stayed on the scene for two hours, leaving the impression that the delay might have caused the death. Actually, the SAMU doctrine allowed the patient to receive extensive care during these two hours, including cardiac ressucitation in the ambulance .
Le premier service de médecine d'urgence a vu le jour en 1869 à l'hôpital de New York City, ou un service assurait le transport basic des malades et blessés.
En 1928, 1er "Rescue squad" à Roanoke (Virginie - USA) se crée, puis les EMS se sont développés depuis les années 60 malgré l'opposition des médecins et pompiers jusqu'aux années 70.... où miracle du petit écran, une série des années 70 intitulé "Emergency" (dont l'histoire se déroulait avec l'équipe de Paramedics du Los Angeles Fire Department) propulse ces EMS naissant au devant de la scène.
En France, c'est en 1955 qu'apparaissent les 1ère équipe mobile de réanimation dont les premières missions consistait dans la prise en charge des accidentés de la route et les transferts inter hospitaliers pour les malades atteints de paralysie respiratoire.
Dès 1965; les SMUR se multiplie avec la parution du décret ministériel sur la création des SMUR.
Les SAMU naissent en 1968 pour coordonner les SMUR et s'associent dès 1974 avec le secteur de médecine libérale.
En France, c'est en 1955 qu'apparaissent les 1ère équipe mobile de réanimation dont les premières missions consistait dans la prise en charge des accidentés de la route et les transferts inter hospitaliers pour les malades atteints de paralysie respiratoire.
Dès 1965; les SMUR se multiplie avec la parution du décret ministériel sur la création des SMUR.
Les SAMU naissent en 1968 pour coordonner les SMUR et s'associent dès 1974 avec le secteur de médecine libérale.
Si vous ne connaissez pas cette série (je ne la connaissais pas), allez rencontrer les fans
Sydney police, MASH, Urgences (ER) & New York 911...
SCOOP & RUN
Utilisation de la "GOLDEN HOUR", les chirugiens donnent 1H aux équipes d'intervention pour amener du lieu de l'accident à la "TRAUMA ROOM" tous patient traumatisé; unique moyens de sauver le patient.
délais arrivée sur les lieux > départ à l'hôpital
Airway, Breathing, Circulation, Deficit, Environement...
"trauma is treated with diesel first"
"treat first what kill first"
The strategy developed for prehospital care in North America is called Scoop and Run. It is based on the Golden Hour theory, i.e., that a victim's best chance for survival is in an operating room, with the goal of having the patient in surgery within an hour of the traumatic event. This is appers to be true in cases of internal bleeding, especially penetrating truama such as gunshot or stab wounds. Thus, the minimal prehospital care is performed (ABCs, i.e. ensure airway, breathing and circulation; external bleeding control; spine immobilization; endotracheal intubation) and the victim is transported as fast as possible to a trauma center. This philosophy is aptly summarized by the following quotation from "The Rules of EMS": "Trauma is treated with diesel first." The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes of arrival; hence the birth of the phrase, "the platinum ten minutes" (in addition to the "golden hour"), now commonly used in EMT training programs. It should be noted the "Scoop and Run" is a method developed to deal with trauma, rather than strictly medical situations (e.g. cardiac or respiratory emergencies).
STAY & PLAY
The stay and play strategy was designed in France with the SMUR (Service Mobile d'Urgence de Réanimation, emergency mobile resuscitation unit) and SAMU (Service d'Aide Médicale d'Urgence), as it was noted that an unacceptable number of patients were dying during transport. The French thus developed a strategy based on maximum care before transportation. Prehospital medical care is provided by a medical doctor MD, a nurse and an ambulance technician, with almost all the equipment and drugs that can be found in an emergency department. The priority here is the stabilization of the patient prior to transport, including intravenous drip to raise the blood pressure (one of the causes of death during transportation is the drop in pressure, which decreases perfusion of the brain and heart; see shock). The German EMS is very similar to the French system.
In case of a severe myocardial infarction (or heart attack), all care is performed onsite (including the possibility of thrombolysis), and the victim is transported only if the heart starts again or the patient is declared dead. Defibrilation is performed by a firefighter rescue team with an automated external defibrillator if they arrive before the medical team. Note that this example is one of the only "real" stay and play approaches performed in France; in most cases, the treatment by the physician is fast and the patient is transported to the hospital within the golden hour.
Les médecins Français ont étudié le nombre de décès lors de transport, et ont orienté leur démarche vers une stabilisation du patient avant le transport surtout en cas d'ACR pour lequel la route vers l'hôpital ne sera envisagé qu'avec un patient vivant ou mort, alors que certains pays vont ventiler et masser jusqu'à l'hôpital.
PLAY & RUN
C'est un mixte des 2, prise en charge des traumatisés graves (seul traitement réel : le bloc), mais utilisation du temps ne pouvant pas être réduit (désincarcération) pour la stabilisation et la médicalisation de la victime.
objectif : pression artérielle normale (9 de systolique) puis évacuation rapide avec moyen rapide.
Both the scoop and run and the stay and play strategies have their advantages and drawbacks. The synthesis of these two opposite strategies has led recently to a new concept: the play and run. The time that cannot be reduced (e.g. while extracting a victim trapped in a car) is used to perform medical care. The treatment aim is no longer to recover a "normal" blood pressure, but a minimal blood pressure, using not only intravenous drip but also vasocompressing drugs and antishock pants (to compress the legs and push the blood into the rest of the body). The aim is to reduce the risk of death due to transportation trauma while respecting the golden hour. The problem with play and run lies in the difficulty of getting a good IV stick in a moving vehicle and controlling the volume of IV fluids given to the patient. Too little fluid will cause inadequate circulation and heart failure, while too much fluid will cause excessive loss of oxygen-bearing blood.
....DE NIVEAU DE FORMATION
Two levels of care are provided by EMS systems: Basic Life Support and Advanced Life Support (BLS and ALS).
BLS providers are CFRs (Certified First Responders) and EMTs, or EMT-Bs (Emergency Medical Technicians-Basic), and provide all care outlined in the EMS standard of care, except for invasive procedures and (to a certain extent) giving medications. EMTs also rarely receive training in EKG interpretation, one of the most basic ALS skills.
ALS providers are principally paramedics and EMT-Intermediates (EMT-I), who are certified to perform invasive procedures and to give a wide variety of drugs. The biggest difference between EMT-I's and Paramedics is that while EMT-I's handle advanced airway management like Paramedics, they do not have as in-depth cardiac training and usually administer fewer medications. There are also Rescue EMTS who are certified and/or have the training in water rescue or in motor vehicle extrication using the jaws of life in medically directed rescue.
In times of economic crisis and in poorer areas, much normal medical care is provided through emergency services to patients who do not have regular physicians or regular medical attention.
EMTs loading an injured skier into an ambulance
An emergency medical technician or EMT (American English) is an emergency responder trained to provide emergency medical services to the critically ill and injured.
Once thought of as an "ambulance driver or attendant," the modern EMT performs many more duties than in the past, and responds to many types of emergency calls, including medical emergencies, hazardous materials exposure, childbirth, child abuse, fires, injuries, trauma and psychiatric crises.
EMTs are trained in basic medical knowledge and skills. Patient treatment guidelines are described in protocols following both national guidelines and local medical policies. The goal of EMT intervention is to rapidly evaluate a patient's condition and to maintain a patient's airway, breathing and circulation by CPR and defibrillation. In addition, EMT intervention aims to control external bleeding, prevent shock, and prevent further injury or disability by immobilizing potential spinal or other bone fractures, while expediting the safe and timely transport of the patient to an hospital emergency department for definitive medical care.
In the United States, EMTs are certified according to their level of training. Individual states set their own standards of certification (or licensure, in some cases). All EMT training must meet the minimum requirements as set forth in the U.S. Department of Transportation's standards for the EMT-B (Emergency Medical Technician - Basic) curriculum.
The National Registry of Emergency Medical Technicians (NREMT), a voluntary standards and testing body, recognizes three levels of EMT: EMT-B (Basic), EMT-I (Intermediate) and EMT-P (Paramedic). Some states such as California use an EMT-I or "EMT-One" Roman numeral designation which is equivalent to the National EMT-Basic; this should not be confused with the EMT-Intermediate (hereafter EMT-I). New York State (and several others) have an EMT-CC (Critical Care) certification, however this is not a national standard. An ambulance with only EMT-Bs is considered a BLS or Basic Life Support unit whereas an ambulance with EMT-Ps is dubbed an ALS or Advanced Life Support unit.
An EMT-B is the highest level of training one can receive without actively functioning as an EMT and being sponsored by one's EMS (Emergency Medical System/Service) organization or a hospital.
Some states, namely Tennessee, utilize a slightly modified NREMT-B curriculum. This includes the standard NREMT-B Skills, although adds several more advanced skills, termed Extended Life Support. Tennessee EMTs are also trained in use of the PTL and CombiTube advanced airway adjuncts, and the activation of Aeromedical Assets. Tennessee EMT-IVs are licensed after passing the NREMT-B test and an in-house skill testing at the training location.
Regardless of their level of training, an EMT's actions in the field are governed by state Regulations, local regulations, and by the policies of their EMS organization. The development of these rules is guided by a physician, often with the advice of a medical advisory committee. A physician acting in direct supervision of an EMT program is referred to as a Medical Director and the supervision provided is referred to as Medical Direction.
In California, for example, each county Local Emergency Medical Service Agency (LEMSA) issues a list of standard operating procedures or protocols, under the supervision of the California Emergency Medical Services Authority (EMSA). These procedures often vary from county to county based on local needs, levels of training and clinical experiences. In other areas a list of permitted actions ("Acts Allowed" list) is issued by a state or local authority.
Some EMTs may be authorized to perform advanced medical skills such as the use of intravenous fluids ( IVs). Some skills may be performed "by protocol" given that certain conditions exist, or "off-line medical direction." Other skills require the prior approval of a physician by radio or telephone, or "on-line medical direction." Some areas maintain an "Austere Care Protocol" which modifies the level of care provided during communications failures or disasters.
Paramedics (EMT-Ps) receive more advanced education and training, including instruction on pharmacology and the administration of lifesaving drugs; the technique of inserting a breathing tube into a person's lungs as in intubation; and even surgical techniques such as sticking a hollow needle directly into the trachea (needle cricothyrotomy) or the chest when necessary to save a life.
Employment of EMTs
EMTs may be employed by a commercial, hospital or municipal EMS (Emergency Medical Service) agency or fire department. Some EMTs may be employed by commercial ambulance services (usually) providing non-emergency patient transportation, or providing emergency medical services to "9-1-1" emergency calls under contract with municipalities or county governments. Some EMTs may work in clinical settings, such as a hospital's emergency department, while others may be employed in an industrial setting, or for 'home health care' providers.
EMTs may be employed by private ambulance services, which usually provide non-emergency transportation of in-hospital patients. Many ambulance services provide transport for patients not experiencing an emergency, but nonetheless requiring medically supervised transportation. Such patients may include those being transferred between hospitals, bedridden patients being discharged to nursing homes or patients who are to undergo specialized treatment, therapy or diagnostic procedures.
In many locales, firefighters and some police officers (particularly in the Highway Patrol) are now also cross-trained as EMTs; the majority of these are EMT-Bs, although a growing number of prospective firefighters earn EMT-P certification in order to increase their chances of being hired. Some large companies, especially industrial facilities, even maintain their own in-house EMTs as part of the plant's firefighting or security guard force.
EMTs may also serve as an unpaid volunteer for a volunteer ambulance service, volunteer rescue squad or volunteer fire department, especially in rural or suburban areas. Rural communities often find it difficult to finance emergency medical services, and recruiting, training and retaining volunteer EMTs is a continuing challenge. This is especially true in small communities since the EMTs who volunteer often know personally the patients they're dealing with.
In response to nursing shortages, EMTs are being increasingly used in the emergency rooms and Intensive Care Units of hospitals, where they can serve as ER technicians, with varying scopes of practice.
Currently, in the United States of America, the busiest EMS service per ambulance is New Orleans' Health Department EMS, which responds to approximately 4,000 "911" calls per month, utilizing six ambulances for the entire city of about 500,000 people.
EMTs and paramedics of the New York City Fire Department's Emergency Medical Service Command, along with hospital employed EMTs and paramedics under its jurisdiction, responds to over 3,000 requests for 911 assistance daily; over 1.3 million calls annually (2003).
EMT : Emergency Medical Technician
BASIC LIFE SUPPORT
First aid is the immediate and temporary aid provided to a sick or injured person until medical treatment can be provided. It generally consists of series of simple, life-saving medical techniques that a non-doctor or lay person can be trained to perform with minimal equipment.
The Knights Hospitaller were probably the first to specialize in battlefield care for the wounded. St. John Ambulance was formed in 1877 to teach first aid (a term devised by the order) in large railway centres and mining districts. The order and its training began to spread throughout the British Empire and Europe. As well, in 1859 Henry Dunant helped organize villagers in Switzerland to help victims of the Battle of Solferino. Four years later, four nations met in Geneva and formed the organization which has grown into the Red Cross. Developments in first aid and many other medical techniques have been fueled in large by wars: the American Civil War prompted Clara Barton to organize the American Red Cross. Today, there are several groups that promote first aid, such as the military and the Scouting movement. New techniques and equipment have helped make today's first aid simple and effective.
It is best to obtain training in first aid before a medical emergency occurs. One needs hands-on training by experts to perform first aid safely, and recommendations change, so that training should be repeated every three years. CPR recertification is recommended annually. Training in first aid is often available through community organizations such as the Red Cross and St. John Ambulance. In many countries in the Commonwealth of Nations, St. John Ambulance provides first aid training and in some countries operates ambulance services. In the United States, the American Heart Association and American CPR Training also offer first aid training.
In the United Kingdom, there are two main types of first aid courses offered. An "Emergency Aid for Appointed Persons" course typically lasts one day, and covers the basics, focusing on critical interventions for conditions such as cardiac arrest and severe bleeding, and is usually not formally assessed. A "First Aid at Work" course is a four-day course (two days for a requalification) that covers the full spectrum of first aid, and is formally assessed. Other courses offered by training organisations such as St John Ambulance include Baby & Child Courses, and courses geared towards more advanced life support, such as defibrillation and administration of medical gases (oxygen & entenox).
Basic First Aid
This is intended as a quick guide only. Effective CPR and first aid require hands-on training that is best accomplished by attending a class in person. (See list above for organizations).
This section summarizes one common formula for performing first aid.
1. Survey the scene What's going on? Is it safe for me to approach?
2. Do a primary patient survey Airway, Breathing, Circulation (the "ABC's")
3. Call for emergency services
4. Do a secondary patient survey, and provide appropriate emergency first aid
Perform a secondary survey only if you are sure that the victim has no life-threatening (ABC) conditions.
It is also essential that stages be performed in order, with the interview first, so that in case the patient loses consciousness all verbal medical and related information has been obtained. Additionally, any information obtained should be recorded, with some organizations employing standard forms that have multiple copies for emergency medical personnel.
EMT-Basic (BLS ambulance)
Basic life support (BLS) is a specific level of prehospital medical care provided by trained responders, including emergency medical technicians, in the absence of advanced medical care.
Basic Life Support consists of a number of life-saving techniques which are focused on the "ABC"s of prehospital emergency care:
• Airway: the protection and maintenance of patient airway including the use of airway adjuncts such as an oral or nasal airway
• Breathing: the actual flow of air through respiration, natural or artificial respiration, often assisted by emergency oxygen
• Circulation: the movement of blood through the beating of the heart or the emergency measure of CPR
BLS may also include considerations of patient transport such as the protection of the cervical spine and avoiding additional injuries through splinting and immobilization.
BLS generally does not include the use of drugs or invasive skills, and can be contrasted with the provision of Advanced cardiac life support (ACLS). Most lay person can master BLS skill after attending a short course. Fire fighter, police officers and lifeguards are required to be BLS certified. BLS is also immensely useful for many other professions, such as daycare providers, teachers and security personnels.
CPR provided in the field buys time for higher medical responders to arrive and provide ACLS. For this reason it is essential that any person starting CPR also obtain ACLS support by calling for help via radio using agency policies and procedures and/or using an appropriate emergency telephone number.
An important advance in providing BLS is the availability of the automated external defibrillator or AED, which can be used to deliver defibrillation. This improves survival outcomes in cardiac arrest cases, sometimes dramatically.
The U.S. Department of Transportation (D.O.T.) recognized a gap between the typical eight hours training required for providing advanced first aid (as taught by the Red Cross) and the 120 hours typical of an EMT-Basic program. Also, some rural communities could not afford the comprehensive training and highly experienced instructors required for a full EMT-Basic course. The First Responder training program began in 1979 as an outgrowth of the "Crash Injury Management" course.
In 1995 the D.O.T. issued a manual for an intermediate level of training called "First Responder." This training can be completed in forty to sixty hours. Importantly, this training can be conducted by an EMT-Basic with some field experience - which is a resource available "in-house" for many volunteer fire departments who do not have the resources for full EMT training. The first responder training is intended to fill the gap between First Aid and EMT-Basic.
First Responder Skills and Limitations
Lifesaving skills in the first responder course include recognizing unsafe scenes and hazardous materials emergencies, protection from bloodborne pathogens, controlling bleeding, applying splints, conducting a primary life-saving patient assessment, in-line spinal stabilization and transport, emergency defibrillation, when to call for more advanced medical help, and the use of oxygen and airway adjuncts. However, a first responder does not have an EMT's skill at patient assessment and evaluation, nor responding to less common emergencies or providing transport using a gurney or stair chair. For example, first responders do not have enough training to work as paid employees on an ambulance crew.
A certified first responder can be seen either as an advanced first aid provider, or as a somewhat limited provider of emergency medical care.
Traditional First Responders
The first responder training is considered a bare minimum for emergency service workers who may be sent out in response to a call for help and is almost always required for professional firefighters.
The first responder level of emergency medical training is often required for police officers (in California, this training is referred to as "Title 22" after the law mandating such training).
Non Traditional First Responders
Many persons can be trained as first responders who would otherwise receive only an eight-hour first aid class. Typically, these persons are selected for first responder training because they are either likely to be the first on the scene of a medical emergency, or because they work far from medical help. These non-traditional first responders include:
lifeguards,park rangers,utility workers, teachers, childcare workers and school bus drivers, worker-volunteers in a large facility (industrial plant) or at a remote site (fish-packing plant, commercial vessel, oil rig), truck drivers, security guards, bodyguards,
general aviation pilots and commercial flight attendants, sports coach.
First responder training is a cost-effective way to extend the reach of the emergency medical system, but not a substitute for EMT-Basic training for those employed to provide emergency medical services on a daily basis.
First responders in France
In France, the prehospital care is either performed by first responders from the fire department (sapeurs-pompiers, most emergency situations) or from a private ambulance company (relative emergency at home), or by a medical team that includes a physician, a nurse and an ambulance technician. The intermediate scale, the paramedics, is only a recent evolution and is performed by nurses specially trained acting with emergency protocols. The first responders are thus the most frequent answer to emergency calls.
First aid associations (about 15 nationwide associations, including the French Red cross, St John of Malta and the volunteers of the Civil protection) also train their volunteers as first responders; the diploma (CFAPSE) is exactly the same as the firemen. They usually act in preventive first aid post, e.g. for concerts, sporting or cultural events.
The volunteers first responders can take part of an emergency rescue team in case of disaster; due to the bad response time (usually some hours to gather the teams), they usually deal with minor casualties, but could theoretically act in first line. In some places (e.g. in Paris), the volunteers take part of the public rescue and partly replace the firemen during the week-ends.
The diploma required to be first responder is the CFAPSE (certificat de formation aux activités des premiers secours en équipe, "certificate of training to team first aid"). It lasts about 50-60 hours, and the final exam is under the responsibility of a physician, a representative to the préfet (responsible of emergency situations in the département) and several instructors (usually from various associations and from the fire department). They must also follow every year 6 hours of continuing training.
The first responders activity is called secourisme ("rescuism") or prompt secours ("fast aid"), to make the difference with the premiers secours ("first aid") performed by the bystanders (although the name of the diploma contains the words premiers secours...).
The CFAPSE (50-60h) is made of ten modules:
• E 1. - the CFR team (team work, organisation of the civil defense and integration in an emergency operation, as professional rescuer or as community emergency response team)
• E 2. - Assessment and evaluation and voice radio communication
• E 3. - emergency casualty movement and patient positions for transportation
• E 4. - Casualty lifting
• E 5. - Casualty movement
• E 6. - Bleedings, wounds, burns
• E 7. - airway permeability (recovery position made by three CFR after motorcycle helmet removal and neck immobilisation by a cervical collar, mouth vacuum aspiration of mucosity)
• E 8. - Mechanical ventilation with devices (bag valve mask)
• E 9. - Oxygen first aid, cardiopulmonary resuscitation and Automated external defibrillation
• E 10. - Immobilisations (splints)
It is possible to follow only a partial course (12h) with the E1, E2, E7, E8 and E9 modules. This "first-level" course is called the attestation de formation complémentaire aux premiers secours avec matériel–AFCPSAM (additional first aid course with equipment).
Wilderness (or mass emergency) First Aid
Wilderness first aid is the provision of first aid under conditions where the arrival of emergency responders or the evacuation of an injured person may be delayed due to constraints of terrain, weather, and available persons or equipment. It may be necessary to care for an injured person for several hours or days.
In the United States, Wilderness First Aid (WFA) is the name of a certification in wilderness medicine that covers wilderness first aid; depending on the laws applicable where it is practiced, it may impose specific responsibilities and confer specific immunities on duly-diligent practitioners. For instance, the practicing of certain rules of WFA, by someone certified in the usual "street" First Aid discipline but not in WFA (or a higher Wilderness Medicine qualification), could result in civil liability or perhaps even criminal prosecution.
A classic problem is whether to leave an injured person or stay, if only one person is ambulatory. Barring special circumstances, the injured one should be stabilized, placed in shelter, and marked in a way visible from the air (usually a single long line of cut brush or trampled snow). Then the injured one should be left alone, while the other goes for help.
If there are three or more, the healthy group should be split into halves by speed, with the fastest going for help, and the others remaining to make the preparations. (In a party of four, it would be a rare hiker who would be better sent for help alone, rather than sent in a sub-party of two.)
Ensuring the rescuers can find the injured person is crucial. If a personal locator beacon is available, it should be triggered and placed with the injured person. If enough help is available, air-visible markings may be worthwhile. Where surveyor's tape is available within the party (and assuming clear trails are available), it should be used by the sub-party going for help to back up memory and notes with tape-flagging of the toward-the-injury-location choices of trail at intersections. (When an injury location is off clear trails, or distances that make it impractical to keep blazes of tape within sight of each other, forks in watercourses should be used as substitutes for trail intersections.)
See medical emergency for a list of medical emergencies and specific guidance directed towards first-aiders, Outdoor Emergency Care technicians and EMTs, often including evacuation criteria.
Training in wilderness first aid is available. Any group of persons traveling in wilderness should have at least one person trained in wilderness first aid and carry a first aid kit designed for the area they are traveling in.
Nursing care is not part of normal first aid but is part of wilderness first aid.
EMT-Intermediate (ALS ambulance)
additional training is provided in AED, LMA, Epi Auto-Injectors, prescribed inhalers, and intraosseous infusion .
The initial EMT-Intermediate course is a minimum of 64 classroom hours and 16 hours of clinical experience.
The refresher EMT-Intermediate course is a minimum of 36 classroom hours .
Intermediate/Enhanced providers will be able to do the following skills:
- Endotracheal airways
- Esophageal airways
- Intravenous access
- Medication administration
EMT-Intermediate/Enhanced is based upon the EMT-Intermediate/85 National Standards Curriculum for EMT-Intermediate/Enhanced. The skills that these providers can perform are:
- EMT-Intermediate/Enhanced skills
- Cardiac monitoring
- Nasotracheal airways
- Needle decompression
EMT-Enhanced and EMT-Intermediates can either function by themselves at an advanced level of practice while working for a Nevada state permitted advanced life support agency or work as part of the pre-hospital care team, working along side a paramedic.
Potential employers include: fire departments, ambulance companies, and mines.
- EMT-Intermediate/Enhanced Prerequisites
- EMT-Advanced (Paramedic)
EMT-Paramedic (ALS ambulance - MICU)
The paramedic program consists of three phases:
Classroom portion (470 hours)
Clinical (hospital) rotations: (150 hours)
Field rotations (480 hours)
A paramedic, is a highly trained medical professional who responds to medical and trauma emergencies in the pre-hospital setting ("in-field") for the purpose of stabilizing a patient's condition before and during transportation to an appropriate medical facility. Paramedics most often will transport patients to an Emergency Department, but "Treat-and-Release" practice can occasionally occur, local protocols permitting.
In the United States, emergency medical technicians are classified according to their level of training. The paramedic is the most advanced level of training as an Emergency Medical Technician (EMT), and they are designated as an EMT-P. A Paramedic can also be a NREMT-P (Nationally Registered Emergency Medical Technician-Paramedic). The National Registry of EMTs is a private, central certifying entity whose main purpose is to maintain a national standard and assist in the ability of paramedics to perform their job functions should they relocate from the state in which they gained certification. Individual states set their own standards of certification, often based on or identical to, the National Registry. All EMTs must meet the minimum requirements as set forth in the U.S. Department of Transportation's standards for EMT curriculum. The National Registry of Emergency Medical Technicians recognizes three levels of EMT: EMT-B (Basic), EMT-I (Intermediate) and EMT-P (Paramedic).
In the field, the levels of training are separated into BLS (Basic Life Support), ILS (Intermediate Life Support) and ALS (Advanced Life Support) units. In addition to the basic-level skills CPR, first aid, airway management, oxygen administration, spinal immobilization, traction splinting, bleeding control and splinting, as well as the intermediate skills of IV therapy, endotracheal intubation and initial cardiac drug therapy, the paramedic is also educated in EKG interpretation, advanced respiratory support and airway skills including RSI, pharmacology, trauma resuscitation, pediatric life support and advanced cardiac life support. Some U.S. states, and the National Registry, require ongoing continuing education and verification of clinical skills capability to maintain a paramedic certification. Other states have permanent certification, except for issues involving gross negligence and malpractice. A Paramedic cannot perform advanced life support maneuvers while off-duty. Since all paramedics in the U.S.A operate under the command of a medical doctor, any advanced life support techniques performed while not under medical command can be considered practicing medicine without a license. Other countries, such as Australia, have different registration systems and it is not illegal to perform invasive medical procedures while off-duty.
Typical view of the defibrillator operator. The leader is at the head of the patient, administrating oxygen. Note how the head of the patient in secured between the leader's knees. The defibrilation patches are on.
Paramedics are employed by various public and private emergency services providers. These include private ambulance services (non-911), fire departments & the 9-1-1 system, hospitals, law enforcement agencies, the military, or various EMS-specific, or "third service" public safety agencies. Paramedics may respond to medical incidents in an ambulance, rescue vehicle, helicopter, fixed-wing aircraft, motorcycle, and increasingly in fire suppression apparatus.
As nursing shortages become more and more prevalent, paramedics are increasingly used in Emergency Departments and Intensive Care Units of hospitals. Often, paramedics operate with greater latitude and autonomy than many nurses. In addition, paramedics are often used as chief medical personnel on offshore drilling platforms and on MEDEVACs and airplanes. However, paramedics may be employed in many different medical fields that do not necessarily involve transportation of patients. Such positions may include phlebotomy, blood banks, research labs and educational fields.
In the U.S., paramedic salaries can range anywhere from unpaid, volunteer positions to as much as $90,000 a year, depending on location, experience, and supervisory responsibilities. It should be noted that volunteer paramedics can generally provide the same level of care as those performing the service in a career capacity, depending on the local scope of practice.
Prior to the 1970s, ambulances were staffed with advanced first-aid level responders who were frequently referred to as "ambulance drivers." There was little regulation or standardized training for those staffing these early emergency response vehicles. However, after the release of the National Highway Traffic Safety Administration's "White Paper" on motor vehicle fatalities, a concerted effort was undertaken to improve emergency medical care in the prehospital setting.
Pittsburgh, Pennsylvania, Baltimore, Maryland, Portland, Oregon and Seattle, Washington were early pioneers in prehospital emergency medical training. Pittsburgh's Freedom House paramedics are credited as the first EMT trainees in America. Baltimore's R. Adams Cowley is referred to as the father of trauma medicine. He devised the concept of integrated emergency care, designing the first civilian Medevac helicopter program and campaigning for a statewide EMS system. Portland's Leonard Rose, M.D., in cooperation with Buck Ambulance Service, instituted a cardiac training program and began to train other paramedics. In Seattle, the Medic One program at Harborview Medical Center and the University of Washington Medical Center, started by Leonard Cobb, M.D., began training firefighters in CPR in 1970. At the same time, the Los Angeles County Fire Department also began training some of their firefighters in emergency care. This was vividly portrayed in the television show, Emergency! which helped popularize the emergency medical service around the world. James O. Page is often referred to as the father of fire department-based EMS because of his roles as the LAFD chief in charge of the firefighter/paramedic program, the expert consultant for the show Emergency!, and the founder of JEMS.
The first paramedics began operating in the 1970's with expansion throughout the country since that time.
A few years later, emergency medical helicopters or MEDEVACs were put into service in the Denver and A.L.E.R.T. Kalispell, Montana areas. It is now routine to have paramedic and nurse staffed EMS helicopters in most major metropolitan areas. The vast majority of these aeromedical services are utilized for critical care air transport (inter-hospital) in addition to emergency medical services (pre-hospital).
Critical care transports are usually requested when a medical treatment facility (usually a smaller hospital) does not have the personnel, equipment, and/or services to definitively treat a patient. The patient is then rapidly transported to another medical treatment facility (usually a large hospital or health system located in close proximity to or within highly populated areas) that has the capability to either definitively treat or to extend or enhance treatment to a higher level. These critical care transports can occur by ground ambulance or aircraft. They are usually the reason why a nurse is needed in addition to a paramedic in the transport team. The nurse usually has experience and may be credentialled in critical care medicine. Recently, paramedics have received critical care medical training both in the initial paramedic certification course as well as continuing education courses such as the Critical Care Emergency Medical Transport Program (CCEMTP). This training has started to shift staffing of Critical Care transport units away from using nurses as often.
The employment of paramedics depends on the organizations that operate the ambulances and other emergency vehicles which they are deployed in. Paramedics responding to a typical emergency may work for the local fire department and arrive in a fire truck or an ambulance bearing the department's insignia, work for a private organization such as a private ambulance and medical transport company, or work for a hospital or health care system.
There are great disparities from nation to nation and within the U.S. as to what training level and skills are required of Paramedics. The National Registry of Emergency Medical Technicians, a private certifying body, has attempted to set a national standard of care for Paramedics in the US, but this has not been fully accepted by all states and even many who have continue to modify slightly the practices allowed to be performed by Paramedics.
Paramedic training programs can last as little as 8 months or as long as 4 years. The national average of curriculum time is 2 years. Many universities now offer four-year degrees in emergency medical services, but as a relatively young industry, professional standards and training levels are still evolving. Regardless of educational path, the paramedic student must meet the same state requirements (course hours) to be eligible to take the certification exams as well as the National Registry exams.In addition, most locales require paramedics to attend an ongoing schedule of refresher courses in order to maintain their license and/or certification.
Paramedics are trained to evaluate and manage the acute stages of nearly all medical conditions. Special emphasis is placed on recognizing and treating potentially life-treatening conditions such as myocardial infarction (heart attack), stroke, breathing problems, overdoses, traumatic injuries, and childbirth.
Specifically, paramedics are trained in airway management, such as intubation, including pharmacologically assisted intubation and increasingly in rapid sequence induction, advanced cardiac life support, including cardiac monitoring, 12-lead electrocardiograms, synchronized cardioversion and transcutaneous (through the skin) pacing; pediatric advanced life support, intravenous cannulation, needle chest decompression, needle cricothyroidotomy, and the administration of a wide range of medications such as morphine sulfate, benzodiazepines such as lorazepam, opioids and dextrose. In addition to certification (both state and National registry), most paramedics are required to be certified in PALS (Pediatric Advanced Life Support) or PPC (Pediatric Prehospital care) or PEPP (Pediatric Emergencies for the Prehospital Provider), PHTLS (Prehospital Trauma Life Support), and ACLS (Advanced Cardiac Life Support). All require additional education and certification from organizations such as the American Heart Association.
Gone are the days, at least in the urban setting, of untrained ambulance drivers. Those in need of emergency medical care have come to expect highly trained medical professionals within four to six minutes of the onset of their emergency. Rapid treatment and transport to a qualified medical facility follow the care given by paramedics in the field. In the most progressive systems in the U.S. the paramedics often screen patients to determine if a medicla problem can be treated in the field, treated by a primary care clinic, or requires transport to an Emergency Department.
As fire departments in the U.S. have seen great declines in the number of structure fires they have begun to branch out into providing emergency medical care in order to better utilize resources and personell, and to avoid budget cuts based on the ever- declining number of fire- related calls.
As the broader medical community moves toward embracing the concept of Evidence- Based Medicine many have begun to look critically at whether or not the considerable money spent providing advanced prehospital care contributes to better long term outcomes of patients. This reaserch has begun to change many once standard practices and will undoubtedly lead to many more changes in the future
Organization and Funding
In the USA,
EMS in the US is delivered through various models. These include;
· Public EMS
o Third Service stand alone
o Third Service hospital based
o Fire Service fully integrated and cross trained
o Fire Service based, non-integrated(includes volunteer fire services)
o Police service based, includes Sheriff's Offices (Police and Fire Services being the first two emergency services)
· Private EMS
o large national companies
o Regional companies
o Small local "mom and pop" companies, and
o 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 in 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.
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. On the contrary it may be financially advantages for a person to die rather than accumulate large medical bills in rehabilitation. (depending on the size or existence of a life insurance policy) This relegates EMS funding to an emotional plea for funds during difficult financial times.
Each State in the USA has control over its EMS, and so more levels of certification may exist. First Responder comes under Basic level, and is the level most fire fighters hold in Tennessee and Virginia. States may also attach add ons to an existing certification. In Tennessee, Most basic level providers are Basic-IV, which simply means they can start IV lines in addition to their Basic level of certification. Other examples such as Intermediate 85 and Intermediate 99 exist, as well as Critical Care Paramedic. Each state decides what it needs based on manpower and money and alters the U.S. Governments recommendations accordingly.
Challenges of the future
In the United States, fire service-based EMS may face funding crises due to rapid increases in EMS calls in a department still devoted to and funded primarily for fire suppression. Compounding these financial difficulties are third party payers such as Medicare which view EMS as a transportion service and not a medical care service. Much of the public has been aware of EMS's medical capabilities since the early 1970s but many third party payers still seem oblivious after over 30 years of EMS successes, and a great number of private EMS providers are happy to fill the lucrative niche of non-emergency transport, perhaps adding to this impression.
Many feel, however, that this state of affairs is bound to change as new technologies continue to spur a drop in the number of fires annually. Already, most firefighters are required to have basic medical training, and many, as noted above, are fully cross-trained as EMTs or even paramedics, and furthermore, the focus on homeland security since the September 11, 2001 terrorist attacks has aided in the integration of what many municipalities still regard as their fire departments' 'bastard son.' In New York City, for example, FDNY firefighters are all trained at least to the CFR level, and many others are EMTs. However, the FDNY firefighters are allowed only to perform at the level of CFR, and the duties of EMT and paramedic are still performed by members of the FDNY EMS Command. These members are employed solely to respond with ambulances to medical emergencies and do not engage in firefighting activities.
One of the major challenges facing EMS in general is the decline of Volunteer EMS units. Paid units typically have less manpower and less on their actual membership role books so that in major disaster, there are actually fewer amounts of trained and qualified rescuers.
Another future challenge facing EMS units is the take over by Fire Departments and Police Departments who strictly see EMS divisions as pure profit - as some paid ambulance runs can be billed at almost $3,000 per patient. Also, many EMS units - both volunteer and paid - still perform medically directed rescue operations such as search and rescue and more specificially motor vehicle extrication - and are losing some of their vital rescue functions as fire departments and police departments take over those rescue functions. Medically directed rescue operations are thinning out and being replaced with fire based rescue. Medical patient care during rescue operations has been pushed to the back burner in many areas and obviously a major future problem facing EMS and patients is the loss of medically directed rescue which has been switching over to non-medical units in many areas. Some fire departments do have medical trained rescuers but that is not common out of city areas.
The future of EMS
The future development of an artificial blood substitute that will carry oxygen will greatly enhance the provision of emergency medical services, as natural blood is rarely available for field transfusions outside military medicine due to scarcity and fragility.
An interim life-saving technique being pioneered by the US military is the use of blood clotting powders such as QuikClot which make it easier to stop previously uncontrollable bleeding from major wounds.
Pioneering advances in telemedicine, including the use of videocameras, now make it possible for advanced medical direction and advice to be supplied to emergency medical technicians, military medics, and nurses or other community health care providers in remote or isolated areas or even aboard cruise ships. One future possibility is the use of robotics to permit a surgeon thousands of miles away to provide life-saving surgery from the comfort of their own office, without requiring emergency travel or exposing themselves to hazards.
PREHOSPITAL EMERGENCY NURSE
ou "INFIRMIER URGENTISTE"
Infirmier diplômé (4 ans de formation), ayant un cursus de formation axé sur l'urgence, le pré-hospitalier plus une formation de type URG'app ou PHTLS/PPC
Pas de reconnaissance réelle en France (ndlr : en espérant la création prochaine de cette spécialité au même titre que les médecins urgentistes), mais existe en Suisse, Belgique, Allemagne, Autriche...
Nurse in France is 4 years training, but there aren't any recognition of prehospital emergency profile,waiting for it, with a additionnal year of emergency practice sort of PHTLS/PPC or URG'app.
There is this kind of recognition in Belgium, Switzerland, Germany, Austria, Spain...
NAEMT ou National Association of Emergency Medical Technician
propose un éventail de formation de médecine pré hospitalière comme le PHTLS (Basic Trauma Life Support ou Adavnced Trauma Life Support) que vous connaissez, l'ACLS (advanced cardiac life support) qui prend de l'expansion, mais aussi le PTS (pediatric life support), ALS (advanced life support).
La mise en place de ces formations nécessite un agrément délivré par des instructeurs NAEMT provenant des états unis pour la formation et la délivrance d'un diplôme à recycler tous les 5 ans
look also TRAINING COURSES PROGRAM
Modèles ATLS, ALS et ACLS
"Advanced Trauma Life Support" (ATLS) is a training program in acute management of trauma cases, developed in 1976 by the American College of Surgeons. The training program has been adopted worldwide in over 30 countries worldwide. The goal of the program is to teach a simplified and standardised approach to trauma patients.
ATLS has its origins in the United States in 1976, when an orthopaedic surgeon Dr James K. Styner, piloting a light aircraft, crashed his plane into a field in Nebraska. His wife was killed instantly and three of his four children received critical injuries. He carried out initial triage to his children at the crash site. Dr Styner had to flagdown a car to transport him to the nearest hospital he found it closed. Even once the hospital was opened and a doctor called in, he found the emergency care provided at the small regional hospital where they were treated was inadequate and inappropriate.
Upon returning to work, he set about developing a system for saving lives in medical trauma sitations. Jim Styner and his colleague Paul 'Skip' Collicott, with assistance from Advanced Cardiac Life Support personnel and the Lincoln Medical Education Foundation, produced the initial ATLS course. In 1980 the American College of Surgeons Committee on Trauma adopted ATLS and began US and International dissemination of the course.
Today ATLS is used throughout the world, it has saved many lives.
Advanced cardiac life support (ACLS) is a detailed medical protocol for the provision of lifesaving cardiac care in settings ranging from the pre-hospital environment to the hospital setting.
Extensive medical knowlege and rigorous hands-on training and practice are required to master ACLS. Only qualified health care providers (doctors, nurses, emergency medical responders) can provide ACLS. Lay persons, however, can master basic life support (BLS) techniques after a short course. In cardiac arrest, immediate BLS support by a lay person before the arrival ACLS personnel & equipment is perhaps the most important step in successful resuscitation. This is especially true now that the use of automated external defibrillators (AEDs) in out-of-hospital setting has become part of BLS. Statistics show that in apparently healthy adults, cardiac arrest often occurs out of hospital.
ACLS is an extension of BLS. It often starts with analysing patient's heart rhythms with a professional defibrillator/pacemaker. In contrast to an AED in BLS, where the machine decides when and how to shock a patient, ACLS team leader makes those decisions based on rhythms on the monitor and patients vital signs. The next steps in ACLS are insertion of intravenous (IV) lines and placement of various airway devices. Commonly used ALCS drugs, such as epinephrine and atropine, were then administered. At this time, the ACLS personnel quickly search for possible causes of cardiac arrest (e.g., a heart attack, drug overdose, or trauma). Base one their diagnosis, more specific treatments are given. These treatments may be medical such as IV injection of an antidote for drug overdose, or surgical such as insertion of a chest tube for those with tension pneumothoraces or hemothoraces. While the above mentioned ACLS steps are being carried out, it is crucial to continue chest compression with minimal interruptions. This point is emphysized repeately in the new ACLS guidelines (see below)
More detailed discussion on ACLS in beyound the scope of this forum. Those interest can find The Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care (ACLS) published in JAMA. The major source for ACLS courses and textbooks in the United States is the American Heart Association; in Europe, it is the ERC (European Resuscitation Council). New version of ACLS guidelines were introduced in December 2005 . New ACLS textbooks will be available in spring of 2006.
Advanced Life Support (ALS) is a treatment consensus for cardiopulmonary resuscitation in cardiac arrest and related medical problems, as agreed in Europe by the European Resuscitation Council, most recently in 2005. It is practiced by in-hospital cardiac arrest teams, which generally consist of junior doctors from various specialisms (anesthetics, general or internal medicine). Emergency medical technicians (EMTs) are often skilled in ALS, although they may employ slightly modified version of the algorithm. (In the US an EMT that has ALS training is known as an EMT-P, or paramedic.)
The treatment algorithms that comprise ALS were agreed by the European Resuscitation Council to improve the outcomes of cardiac arrest.
ALS presumes that basic life support (bag-mask administration of oxygen and chest compressions) are administered.
The main algorithm of ALS, which is invoked when actual cardiac arrest has been established, relies on the monitoring of the electrical activity of the heart on a cardiac monitor. Depending on the type of cardiac arrhythmia, defibrillation is applied, and medication is administered. Oxygen is administered and endotracheal intubation may be attempted to secure the airway. At regular intervals, the effect of the treatment on the heart rhythm, as well as the presence of cardiac output, is assessed.
Medication that may be administered may include adrenaline (epinephrine), amiodarone, atropine, bicarbonate, calcium, potassium and magnesium. Saline or colloids may be administered to increase the circulating volume.
While CPR is given, members of the team consider eight forms of potentially reversible causes for cardiac arrest, commonly abbreviated as "4H4T":
• Hypoxia (low oxygen levels in the blood)
• Hypovolemia (low amount of circulating blood, either absolutely due to blood loss or relatively due to vasodilation)
• Hyperkalemia or hypokalemia (disturbances in the level of potassium in the blood) and related disturbances of calcium or magnesium levels and hypoglycemia (low glucose levels).
• Hypothermia (undercooling)
• Tension pneumothorax (tear in the lung leading to collapsed lung and twisting of the large blood vessels)
• Tamponade (fluid or blood in the pericardium, compressing the heart)
• Toxic and/or therapeutic (chemicals, whether medication or poisoning)
• Thomboembolism and related mechanical obstruction (blockage of the blood vessels to the lungs or the heart by a blood clot or other material)
ALS also covers various conditions related to cardiac arrest, such as cardiac arrhythmias (atrial fibrillation, ventricular tachycardia), poisoning and effectively all conditions that may lead to cardiac arrest if untreated, apart from the truly surgical emergencies (which are covered by Advanced Trauma Life Support).
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...GOOD SAMARITAN LAW
Good Samaritan laws in the United States are laws protecting from blame those who choose to aid others who are injured or ill. They are intended to reduce bystander's hesitation to assist, for fear of being prosecuted for unintentional injury or wrongful death. In other countries good samaritan laws require reasonable action from bystanders (such as calling the authorities). The name Good Samaritan refers to the famous parable told by Jesus in the New Testament.
In the United States
Though the details of Good Samaritan laws in various jurisdictions vary, some features are common:
1. Unless a caretaker relationship (such as a parent-child or doctor-patient relationship) exists prior to the illness or injury, or the "Good Samaritan" is responsible for the existence of the illness or injury, no person is required to give aid of any sort to a victim.
2. Any first aid provided must not be in exchange for any reward or financial compensation. As a result, medical professionals are typically not protected by Good Samaritan laws when performing first aid in connection with their employment.
3. If aid begins, the responder must not leave the scene until:
o It is necessary in order to call for needed medical assistance.
o Somebody of equal or higher training arrives to take over.
o Continuing to give aid is unsafe (this can be as simple as a lack of adequate protection against potential diseases, such as latex gloves to protect against HIV) — a responder can never be forced to put himself or herself in danger to aid another person.
4. The responder is not legally liable for the death, disfigurement or disability of the victim as long as the responder acted as a rational person of the same level of training would have under the same circumstances.
The responder must not commit assault by giving aid to a patient without consent.
Consent may be implied if the patient is unconscious, delusional or intoxicated
— or if the responder had a reasonable belief that this was so; courts tend to be very forgiving in adjudicating this.
Consent may also be implied if the legal parent or guardian is not immediately reachable and the patient is not considered an adult (no matter what the patient claims).
If the victim is not an adult (warning: definitions vary), consent must come from the legal parent or guardian. However, if the legal parent or guardian is unconscious, delusional or intoxicated, consent is implied (with the same caveat as above). Special circumstances may exist if child abuse is suspected.
Laws for first aiders only
In some jurisdictions, Good Samaritan laws only protect those that have had basic first aid training and are certified by the American Heart Association, American Red Cross, American Safety and Health Institute or other health organization. In other jurisdictions, any rescuer is protected from liability, granted the responder acted rationally.
The Good Samaritan Law Report
can't find the reference to this. Need reference or it will be removed!
The Good Samaritan Laws have been established in many States, Alabama is just one of them. These laws were enacted to help to protect the doctors and nurses that help victims and patients from any liability or any civil damages from care that is given in an emergency situation. The definition or actual statement is: a legal principle that prevents a rescuer who has voluntarily helped a victim in distress from being successfully sued for 'wrongdoing.' Its purpose is to keep people from being so reluctant to help a stranger in need for fear of legal repercussions if they made some mistake in treatment. This Good Samaritan Law not only applies to doctors and nurses, but it also applies to other rescue people such as firefighters and police officers. A Good Samaritan Law protects any government official that helps to protect and provide for the people and citizens of both the country and this state. This law protects the majority of people that try to help, however, it does not protect everyone. In order for it to protect, the health care provider cannot be completely careless, they must try to help the person, not take their life. The person providing the help must have consent from the victim before giving and form of care, and the person who is providing the help must do it voluntarily. You are not protected completely by this law; you may still be able to be sued by a victim. The professional should not leave the patient unless another professional that is of equal or greater professionalism arrives to provide medical attention to the victim. “ Negligence and gross misconduct are not defensible.” It states: “ A person who, in good-faith renders emergency medical care or assistance to an injured person at the scene of an accident or other emergency without the expectation or receiving or intending to receive compensation from such injured person for such service, shall not be liable in civil damages for any act or omission, not constituting gross negligence, in the course of such care or assistance.” Federal and State Good Samaritan Laws exist to protect those who assist victims of an accident or crime and the victims themselves. This Good Samaritan Law is to help keep people from not wanting to help others in fear of being accused of “wrongdoing” or being sued for rescuing a “damsel in distress.” One of the readings of this law is the one provided to all states in general in Black’s Law- 7th edition. It states: 'A statute that exempts from liability a person (such as an off-duty physician) who voluntarily renders aid to another in imminent danger but negligently causes injury while rendering the aid. Some form of good-samaritan legislation has been enacted in all 50 states and the District of Columbia.'
In Canada, Good Samaritan Acts are a provincial power. Here is a list of several of the provincial acts:
1. Ontario - Good Samaritan Act, 2001
2. Alberta - Emergency Medical Aid Act
3. British Columbia - Good Samaritan Act
4. Nova Scotia - Volunteer Services Act
Only in Quebec does a person have a duty to respond. 
An example of a typical Canadian law is provided here, from Ontario's Good Samaritan Act, 2001, section 2:
Protection from liability 2. (1) Despite the rules of common law, a person described in subsection (2) who voluntarily and without reasonable expectation of compensation or reward provides the services described in that subsection is not liable for damages that result from the person's negligence in acting or failing to act while providing the services, unless it is established that the damages were caused by the gross negligence of the person. 2001, c. 2, s. 2 (1).
In other countries
Good Samaritan laws describe laws which legally require citizens to assist people in distress, unless doing so would put themselves in harm's way. Citizens are often required to, at minimum, call 9-1-1 or the local emergency number, unless doing so would be harmful, in which case, the authorities should be contacted when the harmful situation has been removed. Such laws currently exist in countries such as Japan, France, Andorra, and Spain. The photographers at the scene of Princess Diana's fatal car accident were investigated for violation of French good samaritan law. In Germany, "Unterlassene Hilfeleistung" (neglect of duty to provide assistance) is an offense; a citizen is obliged to provide first aid when necessary and is immune from prosecution if assistance given in good faith turns out to be harmful. In Germany, knowledge of first aid is a prerequisite for the granting of a driving license.
In pop culture
A Good Samaritan law was featured in the May 1998 series finale of the popular NBC sitcom Seinfeld, in which the show's four main characters were all prosecuted for making fun on an overweight man who was getting robbed at gunpoint rather than helping him.
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