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SC EMERGENCY MEDICAL SERVICES:
THE SYSTEM CONCEPT

An emergency medical system is defined as a system which provides for the arrangement of personnel, facilities, and equipment for the effective and coordinated delivery of health care services in an appropriate geographical area under emergency conditions that occur either as a result of a patient's condition or of natural disasters or similar situations. An EMS system may be administered by a public or private entity which has the authority and the resources to provide effective administration of the system.

EMS systems require the development and implementation of a number of basic components. They are: Training and Education, Evaluation, Accessibility to Care, Critical Care Units, Communications, Disaster Linkage, Medical Record Keeping, Transfer of Patients, Transportation, Mutual Aid Agreements, Public Information, Consumer Participation and Facilities.

Each of these components must exist to the degree necessary for the effective operation of the system, given the geography and demography of the primary area of response. Since EMS is a medical service, it makes good sense that input from an appropriately trained physician be considered during the planning, implementation, and operational phases of a system. EMS can no longer exist outside the mainstream of the medical profession.

The first step in becoming involved in EMS is understanding the capabilities and limitations of the EMS system. That is the purpose of this workshop. By the end of the workshop, you should have a good understanding of the concept of EMS and the role of the medical control physician. Obviously, not every situation can be addressed in a few hours. However, with a good understanding of the system, you will be in a better position to provide medical direction and control.

THE EVOLUTION OF EMS IN SOUTH CAROLINA

 Prior to 1970, with few exceptions, emergency medical treatment in South Carolina consisted of a fast ride to the hospital in the back of a funeral home ambulance, or hearse.

 "A REVIEW OF AMBULANCE SERVICE IN SOUTH CAROLINA", an examination of prehospital providers published in 1968 under the auspices of the South Carolina State Committee on Trauma, revealed an appalling lack of trained ambulance personnel and acceptable ambulance vehicles. The measurement criteria, minimal to say the least, included ambulance equipment on each unit that met the standards of the American College of Surgeons, two-way radio communications, twenty-four hour services, driver and attendant available at all times, and advanced Red Cross training for both driver and attendant. The state committee survey of one hundred ambulance services found only seven services that could meet the designated criteria.

As late as 1971, no statewide training for ambulance attendants existed beyond the level of advanced first aid. The first emergency medical technician (EMT) class graduated from the Lancaster Vocational Education Center in May 1971. Twenty-one emergency medical technicians were certified in 1971. By 1980, over 15,000 people had been certified. At the time of the updating of this manual, 3,002 EMT-B’s (basic EMT’s), 761 EMT-I’s (intermediate EMT’s), and 2,043 EMT-P’s (advanced EMTs) are certified in South Carolina.

 The paramedic program began in South Carolina in 1974. The first class was a cooperative effort of the South Carolina Hospital Association, local hospitals in the Midlands of South Carolina, and the Division of Emergency Medical Services of the state Department of Health and Environmental Control. The first class of twenty students graduated on June 27, 1974.

The ambulance vehicles in use today are mobile emergency departments. The ambulance of twenty years ago would have been equipped with a first aid kit. Today's EMS professional has an impressive armament to deal with critically ill and injured patient.

 The role of the physician in EMS has changed as dramatically as the EMS system in the last two decades. Initially, the physician community was, for the most part, unable to influence the prehospital treatment that patients received. This was true largely because the physician had little contact with the "ambulance driver" who rushed in and out of the hospital. However, the uniformly poor care being given "on the streets" soon raised physician eyebrows. This led to the realization that a critically injured patient's chances of survival could be increased if stabilization was begun prior to arrival at the hospital.

 After physicians realized that the system must be improved, they became involved in the actual training of EMS personnel. The early urban systems in South Carolina benefitted from physician tutelage.

 With the advent of advanced life support, physicians were asked to accept a much more responsible role in the EMS system. Although they would continue to assist in the training of EMS personnel, they were now asked to provide direct medical control for the advanced procedures that were performed in the field.

 The evolution of South Carolina EMS into a technically advanced system of emergency health care delivery is largely due to the voluntary cooperation of many organizations and individuals across the state. These include the South Carolina Department of Health and Environmental Control (DHEC), the regional EMS offices, the state EMS Advisory Council, local governments, hospitals, EMS providers, and the individual physicians, nurses, and EMTs who provide the hands-on care.

THE TRAUMA SYSTEM

 SYSTEM DEVELOPMENT

 South Carolina and DHEC’s Division of Emergency Medical Services has been designating hospitals as trauma centers since the early 1980's In the early years only Richland Memorial Hospital, the Medical University of South Carolina, Greenville Memorial Hospital and Spartanburg Regional Medical Center were designated; they were designated as regional trauma centers.

 In the late 1980's and early 1990's the EMS Section received federal grants from NHTSA (National Highway Traffic Safety Administration) and DTEMS (the Division of Trauma and Emergency Medical Services). These grant funds were used to develop a statewide trauma registry, to establish a Trauma System Committee, to set designation policies and to designate hospitals and to develop a state and regional trauma plans.

 The EMS Advisory Council, on the advice of the Trauma System Committee and the Medical Control Committee adopted the 1993 American College of Surgeons criteria for designations of Level I, II, and III trauma centers. Since the early 1990's to date, the original four Level I hospitals have been redesignated using out-of-state site reviewers and the ACS criteria.

 Additionally, Anderson Area Medical Center was designated by an out-of-state review team as a Level II trauma center. A few years ago, both McLeod Regional Medical Center and Carolinas Hospital System were reviewed by out of state teams and also designated as Level II trauma centers. There are a total of 17 hospitals which have been reviewed by in-state site teams and are currently designated as Level III trauma centers.

 A state trauma plan outlining policies and problems was approved in late 1995. Later, four EMS regional trauma plans were approved through a process of regional meetings and public hearings. The regional trauma plans outline the regional EMS and hospital resources and delineated trauma transport and transfer protocols.

 Medical control physicians are key players in assuring the effectiveness of our trauma system. The off-line medical control physician is required to develop written trauma transport criteria for submission with the service’s other protocols which are due at the time of relicensure. The on-line medical control physician should ensure that trauma transports are being transported appropriately to the nearest designated trauma center, unless stabilization is needed at the local hospital.

 Medical control physicians who are board certified emergency physicians and who currently work at a designated trauma center should also consider signing up for trauma center site reviewer training at the workshop sponsored periodically by the EMS Section.

TRAUMA TRANSPORT PROTOCOLS:

 During the development of the regional trauma plans EMS providers were asked to define where each type of trauma patient would be transported and hospitals were asked to define what trauma patients they could treat and which should be transferred. The proposals of each service and hospital were included in the regional plans. During the course of the development of these plans it became clear that although EMS services had an understanding of where their trauma patients should be transported, many did not have written transport protocols.

 Based on a recommendation by the Trauma System Committee and the Medical Control Committee, the EMS Advisory Council approved a motion “mandating that all EMS services have written trauma transport protocols and that they be included with all other protocols for submission to the state EMS office, with copies sent to the EMS regional offices for inclusion in the regional plans.” This requirement became effective in calendar year 1997.

 EMS services which transport trauma patients directly from the field should submit their written trauma transport protocols, along with their other protocols, as required at the time of relicensure. The protocols should only address to which hospital severe trauma patients will be transported (also pediatric trauma and burns). These protocols should deal with destination criteria, not treatment protocols. Ideally, although not required, EMS services should also have a written protocol for instances when air transport is necessary.

 The Trauma System Committee and EMS Section recommends that the trauma transport protocols be based on the “Triage Decision Scheme” developed by the American College of Surgeons and included as Table 1 in its 1993 edition of “Resources for Optimal Care of the Injured Patient.” (See Appendix.)

 For recent policy changes and trauma system issues currently under review, see the “Year in Review” appendix.