E.M.S. in the 21st Century

1. E.M.S. in the 21st Century Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Clinical Professor of Emergency Medicine George Washington University Bethesda, Maryland, U.S.A. Medical Director, Paramedic Service Reading, Pennsylvania, U.S.A.

2. E.M.S. (Emergency Medical Services) in the 21st Century : Lecture Outline • Ideas on the future of E.M.S. (or "prehospital care") : • Vehicle-based computer communication systems • Electronic patient monitoring units • Telemedicine • Patient care • Business and Education • Robots • Simulator training • Field lab testing and radiographs • Provision of primary health care services • Public education, illness and injury prevention • Home environmental assessments

3. Why is the Future for E.M.S. Bright ? • Lots of energetic and enthusiastic personnel • Support by the public • Recognition of importance by the government • Caseload should not decrease • Increasing population • Increasing percentage of elderly patients • Potential to further utilize existing technology • Multiple roles and responsibilities • "Core" component of national health care system

4. Advanced Vehicle-Based Computer Communication & Monitoring Systems • Perhaps the most important and greatest potential advance for E.M.S. • All motor vehicles can be equipped with small electronic monitoring & communication devices • Should be made standard required equipment • Continually monitor vehicle position via GPS (Global Positioning System, satellite based) • Activate in event of vehicle collision • Then automatically send report to central communications facility

5. Information Relayable from Vehicle Monitoring Sensors • Type and severity of vehicle damage • Vehicle GPS location • Condition of humans in the vehicle • Mental status and major injuries • Environmental hazards or conditions

6. Use of Relayed Information from Vehicle-Based Sensors • The receiving communications center can then send the closest EMS unit to the scene • Can inform EMS units of victim numbers and conditions • Other types of units can be mobilized if needed • Fire, police, heavy rescue, HAZMAT • Prearrival instructions can be sent to the vehicle occupants

7. Advantages of GPS Devices on EMS Vehicles • Allows central control facility to monitor exact positions of all vehicles at all times • Dashboard computerized maps allow crews to determine fastest ingress and egress routes to scenes, and avoid getting lost • Supervisors can also monitor speed of vehicles • Allows more effective Systems Status Management

8. Electronic Medical Monitoring Units for Patients • Small sized units can be carried by patients with recurrent or chronic illnesses • Monitor patient's geographic position using GPS • Activate if patient has sudden illness or incapacitation, and then send location & condition message to communications center • Center can then send EMS unit directly to patient • Could also be used for emergency remote treatment : • External defibrillation if dysrhythmia sensed • Medication injection for other sensed conditions

9. Computerized Communications Between EMS Vehicles and E.D.'s • Hand held or voice activated computers can send detailed info from scene to E.D. (via cell phone transmission) • Hand held P.D.A.'s also useful as references for protocols & medical reference info • E.D. can then print the info to be part of the patient's medical record • This saves the need for the EMS crew to do any other documentation • Continuous 2 way info from E.D to EMS units allows updating on E.D. bed availability & hospital condition or capacity

10. One type of hand-held computer for recording EMS patient information

11. Ambulance vehicle – mounted computer system

12. Advantages of Computerized 2-Way Communications Between EMS & E.D.'s • Allows better management of multicasualty situations • Helps avoid overload of any one receiving facility • Patient medical information can be transmitted much more quickly & completely than can be done verbally • Enables more rapid turnaround of EMS units after delivering patients

13. NATO nurses transporting patient on military “mini-ICU” stretcher

14. U.S. military stretcher with built-in ICU equipment

15. Telemedicine in the Future of EMS • Miniaturized television (TV) cameras can be carried on helmet, hat, or uniform of EMS personnel • Sending live video images of the scene to the communications center helps determine need for additional responding resources • Helps manage multicasualty situations & terrorist incidents • Also allows monitoring for scene dangers not noticed by the EMS crew

16. Other Telemedicine Uses in EMS • Allows hospital-based doctors to assist field EMS personnel to make diagnoses & treatments • Allows hospital physicians to direct EMS personnel to do medical or surgical procedures • Can be used for followup visits or "checkups" for patients with chronic illnesses • Can obviate need for "face to face" meeting with doctor

18. Telemedicine with Robot Units • Video camera equipped robot units : • Can search dangerous environments for victims : • Building fires • Buildings at risk for collapse • Possible chemical, biological, or radiation contamination • Boat or submarine robots can search water areas for victims • Can have chemical detectors • Can perform remotely directed medical or resuscitation procedures

21. Telemedicine for Video Conferencing • Limits travel time & expense for business meetings or educational conferences • Video based training & education materials are easy to transmit & update • Allow personnel to conduct training or receive education in "down time" between calls • Having personnel log on to on-line training programs allows supervisors to monitor completion of training & conduct tests

22. Use of Simulator Training in EMS • Computerized mannequin patient simulators can be used for more realistic clinical training • Allows demonstration of student's ability to recognize problems & take action • Allows more accurate testing of students • Requiring completion of extensive simulator training prior to licensing is protective for the public • Vehicle driving simulators can improve driving skills for low cost

23. Ambulance vehicle driving simulator

24. Field Laboratory Testing by EMS • Hand held miniaturized devices can rapidly measure a wide variety of blood & body fluid components (using only small amounts of blood) • Permits broader & more accurate prehospital diagnoses • May obviate need to transport patient to E.D. • Results may determine type of receiving facility (such as cardiac enzymes or toxin levels)

25. Radiographic Equipment for EMS • If more portable & less costly radiographic equipment is developed, this may be utilizable by EMS units • Transmission of images back to hospital emergency physician or radiologist could be done • Interpretations may obviate need to transport patient to hospital, or permit early thrombolysis • Can be used for verification of endotracheal tube placement • Ultrasound may help with intravenous line placement

26. Expanded Roles for EMS Personnel : Primary Health Care Services • Proposals in U.S.A. for EMS personnel to undertake more primary care services • Due to faults in the U.S. health care system, with deficiencies in access to primary health care & health maintenance services • Also proposed to more fully utilize the "down time" of EMS personnel between runs • May be less expensive for EMS units to see multiple patients at home versus transporting these patients for exams by doctors

27. Proposed Primary Health Care Services for EMS to Undertake • Regular checkups on patients with chronic illnesses • Administer immunizations • Administer long term parenteral meds • Chronic wound care • Blood draws for medication level monitoring • Education reinforcement about managing chronic illnesses and need for preventive measures • Some aspects of hospice-like care

28. Important Roles for EMS in Public Education • Illness prevention and healthy lifestyles • Injury prevention • Promote seatbelt & helmet use • Violence prevention • Safe driving • Greater EMS personnel involvement with local, state, & national governments can promote public health improvements via legislation & regulation

29. Proposed Home "Environmental Assessments" by EMS Personnel • Important to evaluate the home environment, especially for the elderly, for potential problems that could affect health • Check heating & cooling units • Alter furniture, rugs, etc. to limit risk of falls • Identify need for safety equipment such as stair rails • Identify patients with inadequate nutrition or finances who may be candidates for other social service agency interventions

30. Aspects of Future EMS About Which We Need to be Careful • Realization of the limitations of the prehospital environment • Avoidance of new & aggressive treatments until they are proven MORE effective prehospital than if waited to be done in the E.D. • Avoidance of expansion of the types of medications carried by EMS units until proven that new or additional medications offer clear benefit • Important to maintain cooperation & coordination of care between EMS and hospitals

31. Research Important to Conduct in EMS • Patient outcomes from EMS interventions • International comparisons of outcomes in different EMS systems • Comparisons of outcomes between patients transported by ground versus aeromedical units • Effectiveness of different personnel training techniques • Effectiveness of public education programs

32. EMS in the 21st Century Lecture Summary • The future for EMS in the 21st Century is very bright • Expanded use of present technology will allow improved & more efficient EMS care • Vehicle monitoring systems • Telemedicine and robots • Simulator training • Field lab & radiographic studies • EMS can provide more primary & followup care • EMS has much research potential