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EMS Acronyms: ALS? BLS? QRS?

An Overview of EMS
by

Michael Hilton

on 9 January 2013

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Transcript of EMS Acronyms: ALS? BLS? QRS?

A basic guide to EMS EMS Acronyms: BLS? ALS? QRS? EMR: First responder
BLS: Basic Life Support, aka EMTs
ALS: Advanced Life Support, aka Paramedics
QRS: Quick Response Service EMRs multiple types of providers
and services EMRs are emergency medical responders. In some states, they are referred to as "certified first responders." They are prehospital providers who are trained by a state approved certification course to provide basic first aid and stabilizing medical care until a higher-trained provider arrives on scene.

Typically, they do not perform transport of patients. Sometimes, they may assist a higher-trained provider during transport in an ambulance.

They are typically first on-scene due to the nature of their job, such as firefighter, police officer, security guard, industrial safety supervisor, etc.

Their training is typically 40-60 hours in length, is both didactic and skills-based, and is more extensive than a basic CPR and First Aid certification. Scope of Practice Oral and nasal airways
BVM
Suction
Oxygen
Epi-pens
AED
CPR
Manual cervical spine stabilization
Manual extremity injury stabilization
Hemorrhage control
Patient lifting and moving EMRs can be part of a QRS A QRS, or quick response service, is an EMS agency designed to respond to the scene of a medical emergency, just like an ambulance does. Unlike an ambulance, the QRS only provides immediate on scene care and stabilization. It cannot transport.

An ambulance service may or may not respond to the same incident. In some systems, QRS services must request an ambulance after evaluation of the patient. In others, ambulances are simultaneously dispatched. Most systems are a hybrid of each of these.

QRS services are geographically, institutionally or event specific. For example, a national park may have its own QRS. An airport may have QRS. A concert may have a QRS. Similarly, a college, such as Carnegie Mellon University may have its own QRS: CMU EMS. EMTs EMTs are emergency medical technicians. They are the lowest-level of prehospital provider that can perform out-of-hospital medical transport. They typically serve as part of an ambulance service, but some serve as part of a QRS service. CMU EMS, for example, is a volunteer QRS, staffed by EMTs.

EMTs are certified through 110 hour state-approved courses that are didactic and skills-based. Courses also typically require a minimal amount of ambulance and/or emergency department observation time, usually at least 10 hours.

Courses discuss legal aspects of medical care, basic anatomy and physiology, medical history taking and interviewing, patient assessment and treatment of medical, traumatic and psychiatric emergencies. Scope of Practice Oral and nasal airways
BVM
Suction
Oxygen
+/- pulse oximetry and glucometry
Hemorrhage control and tourniquet
Administration of oral glucose
Assist patient in administration of their own albuterol MDI, nitroglycerin, Epi-Pen
Some states: administration of epi-pen, albuterol nebulizer and aspirin (for chest pain)
Extremity splinting and immobilization
Cervical collar and backboard application
AEDs
CPR
Patient lifting and moving
OB delivery
*CPAP (with advanced training)
EMTs are the majority EMS provider Nationwide, 70% of certified EMS providers are EMTs (EMS Workforce Report, NHSTA, 2008)

EMTs may serve on QRS services (e.g., CMU EMS)
EMTs may staff Basic Life Support ambulances. Many of these have two EMTs, but some may have only one EMT. The other crew member is usually an EMR or driver or first aid/CPR trained assistant.
EMTs may staff Advanced Life Support ambulances. In this case, they serve as an assistant to, and driver for, a paramedic.
EMTs may also staff first-aid stations at amusement parks, concerts or community events. Advanced EMTs In some states, Advanced EMTs, also known as intermediate EMTs or EMT-Is, serve as a step between EMT-Bs and paramedics.

The prerequisite for an Advanced EMT certification is an EMT-B certification.

They are certified through state-approved courses that last months to one year, depending on the state. Class time is supplemented by many hours of clinical time on advanced life support ambulances and in hospital settings.

Currently, Pennsylvania does not have Advanced EMTs. Advanced EMTs can provide a limited set of advanced, lower-risk skills.

They are a cost-efficient solution for some regions, particularly rural, that cannot afford paramedic care.

They also require less training than paramedics, so systems that are primarily volunteer-based, may find volunteers who have time and money to undergo this training as opposed to paramedic training.

Advanced EMTs can staff Advanced Life Support ambulances as a primary provider with an EMT-B or a second Advanced EMT as a partner.

Advanced EMTs can staff Advanced Life Support ambulances as an assistant to a paramedic. Scope of Practice The scope of practice of Advanced EMTs varies by state, and some states do not have Advanced EMTs.

Scope of practice includes EMT-B skills plus: King LTD or similar device
Tracheobronchial suctioning of intubated patients
Glucometry
Pulse oximetry
IV access
IO access
Non-medicated IV fluid therapy
Sublingual nitroglycerin
SubQ or IM 1:1000 epi
IM glucagon
IV D50
Albuterol nebulizer
Narcan administration
Nitrous oxide for pain relief Practice Setting Paramedic Paramedics, also known as EMT-Ps, are the highest level prehospital provider that are not part of a specialized critical care ground or air medical transport service, such as STAT MedEvac.

Paramedics become certified through state-approved courses of around 1200 hours of didactic and skills-based training.

This is supplemented by many hours of ALS ambulance and in-hospital clinical training.

Courses may be paired with an associate or bachelor degree. Generally, courses run from between 8 months and 2 years.

Prerequisite to a paramedic certification is an EMT-B certification.

In addition to advanced skills training, paramedics receive additional training in advanced patient assessment, anatomy, physiology and pharmacology. Scope of Practice The scope of practice includes EMT-B skills, plus: Endotracheal/Nasotracheal intubation
King LT or similar device
Magill forceps for foreign body removal
Cricothyrotomy
Needle decompression
CPAP
ETCO2/Capnography
Pulse oximetry
IO access
IV access
Venous blood sampling
IV fluid (medicated and non-medicated) administration
Blood glucose monitoring
Synchronized cardioversion
Manual defibrillation
Transcutaneous pacing
12 lead EKG interpretation
Cardiac rhythm monitoring Paramedic Medications Vary by state and Medical Director approval. Use of some of these requires a consult.
For PA, the list is: activated charcoal
adenosine
albuterol
amiodarone
aspirin
atropine
calcium chloride/gluconate
D50
dexamethasone
diazepam
diltiazem
diphenhydramine
dobutamine
dopamine
epinephrine
etomidate
fentanyl
furosemide
glucagon hydrocortisone
ipratropium
lidocaine
lorazepam
magnesium
methylprednisolone
midazolam
morphine
narcan
nitroglycerin
nitrous oxide
NS/LR
odansetron
pralidoxime
sodium bicarbonate
sterile water
terbutaline
tetracaine
verapamil Service Model Nationally, most Advanced Life Support ambulances are staffed by paramedics.

50% of ALS ambulances are staffed by 1 paramedic and 1 EMT-B.

37% of ALS ambulances are staffed by 2 paramedics (e.g., Pittsburgh EMS)

9% of ALS ambulances are staffed by 1 paramedic and 1 Advanced EMT

4% of ALS ambulances are staffed by 2 paramedics and 1 EMT-B

<1% of ALS ambulances are staffed without a paramedic (i.e., with only an Advanced EMT)

(JEMS 2010 200-City Survey) Bringing it all together The practice of EMS is defined by the States.
The following are set by the state's EMS regulatory body, usually the Dept. of Health: Certification and re-certification requirements
Course content, length, and required clinical hours
Scope of practice and levels of EMS providers
Minimum ambulance equipment and medication list

Therefore, refer to your state's EMS regulations for more specifics about your state's EMS system. For PA, the website is:
http://www.portal.state.pa.us/portal/server.pt/community/emergency_medical_services/14138 Summary of Providers Emergency Medical Responder: "EMR" or "certified first responder" or "CFR"
Provides immediate care, does not transport
Serves on a QRS Emergency Medical Technician: "EMT" or "EMT-B" or "EMT-Basic"
Lowest level of medical transport
Basic Life Support ambulances or QRS services
Majority of EMS providers Advanced EMT: "AEMT" or"EMT-I" or "EMT-Intermediate"
Intermediate level provider
May or may not exist in your state
Rarely found in most regions Paramedic: "EMT-P" or "EMT-Paramedic"
Highest level of transport provider (not critical care)
Advanced Life Support ambulances
Most partner with an EMT-B Note that a service's Medical Director can further limit the medications and skills allowed by that service's EMS providers. Summary of Types of Services QRS (PGH Fire; CMU EMS): First on scene
May be a police dept, fire dept, EMS service
May be associated with a venue, event or business
Provide immediate medical stabilization
Some dispatched alone without a co-dispatched ambulance BLS ambulance: basic ambulance
Staffed by EMT-Bs
Majority of ambulances ALS ambulance (PGH EMS): advanced ambulance
Nearly all are staffed by at least one paramedic Critical Care transport (STAT MedEvac):
Mostly for interfacility transports
Can be ground or air transport
Air transport also may perform EMS rendevous
Usually staffed by a flight nurse and flight paramedic
Expanded scope of practice, training, skills and medication list CMU EMS Starting January 13, we will be performing online medical command for CMU EMS.

CMU EMS is a QRS that responds to emergencies on the CMU campus

It is dispatched by CMU Police Dept. Not all of its responses get a 911 response (i.e., PGH EMS ambulance).

If needed, they call the EOC requesting an ambulance.

In cases where PGH EMS is co-dispatched with CMU EMS, CMU EMS will evaluate the patient and provide updates on the radio to the responding unit.

CMU EMS can cancel PGH EMS if ALS care or transport is not needed.

CMU EMS can also cancel PGH Fire if Fire is dispatched as a QRS by the EOC. If additional manpower or Fire resources are needed, CMU EMS will not cancel PGH Fire. CMU EMS CMU EMS has about 30 EMT-Bs

They carry some equipment when on duty

Additional equipment is carried by police vehicles

They travel on foot, by bicycle or in a police vehicle (driven by a police officer)

Most of their consults are for refusals

They use a nearly identical form to the PGH EMS refusal form

They perform about 86 consults per year Important Points They are a QRS service
They are trained to the EMT-B level
They carry and can use oral glucose and epi-pens
They can assist with a patient's own albuterol MDI and nitroglycerin
They have pulse oximeters
They DO NOT have a glucometer
Their patients may be minors
A PGH EMS ambulance may not be responding
Their patients have alternate definitive care available (CMU Health Services)

Because of alternate care available on campus, some EMS calls may be refusals that are driven by private vehicle (police vehicle) to Health Services.
For example, an ankle sprain in the gym. References:

Bass R, Brice J, et. al., ed. Medical Oversight of EMS. Kendall Hunt Professional and NAEMSP: 2009.

Brennan J, Krohmer J, et al. Principles of EMS Systems. Jones and Bartlett and ACEP: 2006.

Emergency Medical Services at the Crossroads. Institute of Medicine and the National Academies Press: 2007.

EMS Workforce for the 21st Century: A National Assessment. NHSTA 2008. Accessed 12/2012. http://www.ems.gov/pdf/EMSWorkforceReport_June2008.pdf.

Journal of EMS 2010 200-City Survey. JEMS. Accessed 12/2012. http://www.jems.com/sites/default/files/survey.pdf. Pittsburgh EMS PGH EMS is an ALS ambulance service

There are 160 paramedics

Each ambulance is staffed by 2 paramedics
There are 14 ambulances in service

Each rescue truck is staffed by 2 paramedics
There are two rescue truck in service

They perform consults for:

Some medications (e.g., opiates)
Predefined call types (e.g., trauma, stroke, chest pain, etc.)
Destination (e.g., where should we bring a child with trauma and burn?)
Clinical questions
Refusals (refusals for some chief complaints require consult)
STEMIs Pittsburgh Fire Bureau Pittsburgh Fire responds to medical calls as a QRS service

There are 600 firefighters

Its firefighters are trained as EMT-Bs.

They carry AEDs, BVMs, oxygen, collars, and backboards.

They do not perform consults.
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