Emergency Medical Communications (1974)

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“78 7 he. further research and resu:i: ..* improvements in provision of emergency medical services, and in me-. <:.-..:.-orevent the need for such services. a . : oN mn ., GENERAT, CONS LOERATIONS IN EMS COMMUNICATIONS Background The last decade has seen mounting concern among professional and lay organizations over the need for better emergency medical care. Among those who first gave their attention to the problem were the Committee on Trauma of the American College of Surgeons, the Committee on Cardiopulmonary Resuscitation of the American Heart Association, the Committee on Acute Medicine of the American Society of Anesthesiologists, and the Committee on Injuries of the American Academy of Orthopaedic Surgeons. Since 1966, a number of new groups have been formed, including the Commission on Emergency — Medical Services of the American Medical Association, the Committee on * Community Emergency Medical Services of the American Medical Association, the American Trauma Society, the University Association of Emergency Medical Services, the American College of Emergency Physicians, the National Registry of Emergency Medical Technicians and others In July, 1968, the Midwestern Governors Conference, by resolution, requested "federal assistance in the development of coordinated interlocking telecommunications systems." Hitherto, efforts have been concentrated on training of ambulance and rescue personnel, improving hospital emergency department facilities, defining proper emergency medical care techniques, and establishing equipment standards. With these components in process of development, it is now possible to develop emergency medical sy.tems with communications serving as the central nervous system.

Previous recommendations on communications focus on two-way voice mobile communications, dispatching, disaster communications, a universal emergency telephone number, training for medical dispatchers, community © : 1,4,5,22, 23 emergency medical councils, comprehensive planning, and other subjects, but often miss the key point that EMS systems planning and a clear definition of the need to communicate must precede action on problems of equipment. The federal agency most active in behalf of emergency medical communica- tions has been the Department of Transportation (DoT). The Highway Safety Act, enacted in 1966, provided the financial and legislative authorization to improve and expand emergency medical services in the states. Subsequently, the National Highway Traffic Safety Administration of the DOT developed state guidelines (Standard 4.4.11) for the provision of exergency medical care as a part of state highway safety programs. Three out of the eight requirements related to communications are: (1) that there be criteria tor the use of two-way communications, (2) that procedures be created for sum- moning and dispatching aid, and (3) that there be an up-to-date, comprehensive plan for emergency medical services, including “ A. Facilities and equipment. B. Definition of areas of responsibility. C. Agreements for mutual support. D. Communications systems. *For the role of other federal agencies in supporting EMS, see Com- mittee on Emergency Services of the Division of Medical Sciences, Roles and Resources of Federal] Asencies in Support of Comprehensive Emergency Medical Services, Washington, D.C.: National Academy of Sciences - National Research Council, March, 1972. 23

A recently published DOT report ‘calls for "the many separate function systems (fire, police) to be coordinated into a total-use system with ‘cross-_ talk' capability for the multiple services responding to accidents and other emergencies. Planning should include integration of communications facilities as an integral part of, and not in isolation from or parallel to, other facilities." DOT has provided assistance in the planning and development of emergency medical services by funding projects, and has supported more than 300 state and local highway safety projects, including several in the area of emergency communications and improved emergency service systems. Its objectives have, for the most part, been to improve those elements of emergency medical serv- ices that are directly related to highway safety and transportation. Emergency medical communications planning has also been encouraged within the overall context of the programs and projects supported by the Division of Emergency Health Services (DEHS) of the Public Heaith Service. This division has served as a clearinghouse for information, provided guidance and assistance to local, state and other federal agencies involved in EMS programs and has sought to stimulate the development of sound planning, training programs, equipment standards, public education and research in the field. More recently, the Health Services and Mental Health Administration, of which DEHS was a part, sponsored the implementation of demonstration EMS systems in several settings across the nation. The following sections discuss basic principles in emergency medical communications, the functions of the EMS communications system, community organization, and funding. 24

Basic Communications Principles This section will sumarize basic principles and considerations, a number of which have been stated by one or another of the groups mentioned above, and show how they relate to a total emergency medical systen. Area-Wide EMS Systems Emergency medical services systems should serve defined populations in circumscribed geographic areas. Such areas usually will contain one or more hospitals of varying capabilities. An objective of such a system is to make the best use of all resources according to the patients' needs. For such a system to be effective, smaller communities and rural areas must be served by the more extensive medical facilities and personnel found only in larger urban areas. At least one hospital in the system should have a complete emergency capability.* Emergency medical services areas are gradually being defined by local usage, based on patterns of use, types of services and facilities available and the time element involved in the delivery of patients to the hospital. Also relevant are political, geographic, demographic, and other factors. An area may cover a number of counties in a rural state or only a section of a large metropolis such as New York City. Need for arbitration, through _ State emergency medical councils, may arise when jurisdictions overlap. Ultimately, as emergency services areas expand, communications must be planned for larger regions (e.g., administrative subdivisions of states, *Hospital emergency departments in many communities are now being categorized according to their capabilities for providing emergency care; criteria for categorization have been widely publicized. See American Medical Association. Recommendations of the Conference on the Guidelines for the Categorization of Hospital Emergency Capabilities. 1971. Chicago, Ill. 25

that may contain a number of emergency medical service areas). Planning for entire states has been urged by the American Medical Associa- tion and is being promoted by both the Department of Transportation and the Health Services and Mental Health Administration and others. A number of states such as Nebraska, Illinois, and Colorado, are now in the process of devising state emergency medical communications systems which integrate with those of other emergency public protection systems. A recent report of the National Academy of Sciences sums up this re- quirement: "Full collaboration of the communication systems of multiple political jurisdictions within an emergency medical services area are essential to effect ive day-to-day emergency care within that area. In- tegration of multiple areas is essential to optimal response to widespread natural disasters or a national emergency."° Thus: | | \ Emergency medical svstems and the communications that suppce: " them must be planned on an area-wide basis, irrespective of artificial boundaries or local political jurisdictions. Hospitals and ambulances in one area must be able to com- municate with those in neighboring areas. Coordination with Other Azencies The EMS system must be viewed as one part of a total commiui.’ty response capability. Also included are law enforcement, fire, public utility, and disaster relief elements. In many routine emergency situations, and always in the event of disasters, a coordinated response by many agencies is re- quired. Often, however, communications systems are designed for the exclusive use of one agency, with little regard for any of the others. This should 20, 26 not continue: , 26

Emergency medical communications must be planned as an interral part of a total community communication network. Converselv, all communications systems plannins, like that now being carried on at the state level in many states, should include an EMS communications component. Universal Fmergency Telephone Reporting System - With the universal emergency telephone number (911) system, any standard public telephone can be used to call an emergency response center simply by dialing 9-1-1. Coins are usually not required for pay telephones in the system. Therefore, any citizen, by means of an easily remembered telephone number, c2n summon immediate aid. The system,which should be used as entrance to all community emergency systems, has obvious advantages which far outweigh the technical problems of implementation. Like other elements of an EMS communications system, it requires organized community planning before it can be implemented. . Such systems are gradually being accepted and established in various parts of the nation; a few hundred jurisdictions now employ this technique. The areas spanned by these current systems cover populations ranging from a few thousand to several million, and the systems have demonstrated their usefulness when coupled with a well-planned and integrated emergency system designed to respond to the full range of emergency calls received. The commercial telephone system is the largest and most accessible reporting system available. Its effective use must be assured: The 911 universal emergency telephone reporting system | should be implemented on a nationwide basis, and EMS communications svstems should provide for its incorporation. Central Dispatching Whether in the usual mode of responding to the myriad of daily emer- gencies or in the unusual mode of dealing with a major calamity, the 27

coordination of an emergency response is best performed in an area-wide Emergency Communications Center which, for example, receives all 91l telephone, radio, or other emergency calls. Such a system must also have a central point to which all calls requiring medical assistance are immediately transfered. Further, the effective utilization in an emergency response of EMS resources (all hospitals, ambulances, etc. in the system) requires coordination and screening which can best be ac- complished at a central control location. Some community-wide systems may have only one such EMS dispatching center; others (e.g. large metro- politan areas) may have several. The requirement is clear; Central coordination of the response to a medical emergency, including the central dispatching of all emervency ambulances and other rescue units and single-point coordination with other agencies, is essential to an area-wide EMS system. Functions of the EMS Conmunications System | The functions of the emergency medical services communications network are several: (1) to tie together EMS subsystems, thus facilitating patient entry into the system; (2) to assure dispatch of EMS resources to the scene; (3) provide for medically supervised patient care at the scene and at all times while under the management of the EMS; (4) to coordinate transport of the patient to and between treatment facilities; (5) to coordinate the interactions of the various agencies, facilities and manpower within the system; and (6) to coordinate EMS with other public and private services. The communications requirements resulting from these functions can be developed by considering, in turn, the time sequence of events surrounding a medical emergency and the response thereto. 28

Detection and Reporting The detection of emergencies, whether by victims or observers, can be increased in effectiveness first by public education to teach each citizen to recognize promptly an emergency, his own or that of others, and second by inculcating in him a strong sense of responsibility to report it immediately. Once detected, there must be an easy means of reporting the emergency situation. This can be accomplished by the implenentation of the universal emergency telephone number (911), by providing telephones where none exist (e.g. in rural areas), by organizing groups of citizens likely to come upon emergencies (e.g. the nation's bus, truck, taxi and public service auto- motive fleets), and by encouraging the citizen's responsibility through such legal means as good samaritan laws. Where large groups gather, as at sports arenas, or at places of high hazard, EMS facilities, or a "hotline" to an EMS communications center should be established. Dispatch of Aid ‘The dispatching of-aid involves ambulances, rescue units and qualified medical personnel as required. It also can include police, fire, public utility, tow trucks, and other units. At times of major disasters, heavy construction equipment, food, shelter, and other extraordinary services may also be required. Standard dispatching technique should require that the driver of the responding vehicle notify the dispatcher of the time of departure to the scene, arrival at the scene, departure from the scene, delays encountered enroute, arrival at a hospital and readiness for another assignment. The times of these actions should be recorded to permit an analysis of the system response effectiveness and for protection against claims of avoidable delay. 29

In addition to the initial dispatch, the dispatcher should be able to provide routing information to vehicles in transit specifying the quickest route from the standpoint of distance, road conditions and congestion. He also must be able to call ancillary aid from other agencies. Thus, he requires direct or dedicated communication links with, the bases where ambulances are deployed, with all vehicles by means of two-way voice radio, with all hospitals in the system, and with the emergency response dispatchers of other services such as police, fire, civil defense and public utilities. Rendering Cave at the Scene and in Transit Of the many improvements which can now be recognized as essential to quality emergency medical care, the provision of treatment by well-trained emergency medical technicians (EMT's) at the scene and during transit to a hospital, undez the direction of a remotely-located physician, is one of the most important. Depending on local laws and EMT training, life-saving measures performed by the ambulance EMT under physician direction by radio can include tracheal intubation, defibrillation, intravenous fluid therapy and drug administration. In addition, without physician direction, he can control bleeding and perform standard cardiopulmonary resuscitation measures, splinting, etc..- This concept of mobile, physician-directed medical care offers much promise for small communities or rural areas where hospital emergency 14 and where patient departments and doctors are not constantly available, transport times can be as long as several hours. In urban areas, although transport times are usually shorter, the capability and procedures for pro- viding physician-directed treatment must be available. 30

To perform this task, the ambulance EMT's require two-way voice communications with a physician. (A single physician may provide support for more than one ambulance crew). Further, advanced treat- ment techniques require that the physician have access to physiological data and patient history, as well as the EMT's visual observations of the patient's condition. The electrocardiogram (EGG) is one type of virtually continuous data which needs to be provided to the consulting physician. This requires telemetry communications from the patient (e.g. a portable transmitter) and from the ambulance to the physician. Vital signs such as blood pressure, respiration rate, and pulse can be easily determined by the EMT. He can also be trained to recognize critical EGG patterns for which he can solicit action. Transportation to the Appropriate Hospital It is common practice today, particularly in the systems having no two-way ambulance radio communications, for an ambulance to pick up an injured or sick person and deliver him to the nearest hospital, whether or not that hospital is the best one available to treat the specific problem of the patient. In an efficient integrated EMS system, however, the hospital to which the patient is delivered is determined on the basis of the patient's condition and on the capability of the hospital to handle the case. The well-trained emergency medical technician in the ambulance assesses the patient's condition and, using established procedures, consults with the medically trained dispatcher and/or physician, selecting the best destination 31

for the patient. The dispatcher and the ambulance crew are aided in this decision by prearranged, medically established guidelines; for example, severe head injuries to hospital A, B, or C; apparent cardiac cases to hospital B or D; pediatric cases to hospital E; burn cases to hospital F; etc. It must be recognized that this procedure may be modified by direc- tions from the patient's physician, family, or the patient himself, and by hospital capacity at the time. The procedure requires ambulance-hospital-dispatcher-physician com- ~~ munications links. The dispatcher should be cognizant of the emergency medical capabilities of each hospital in the area, have available up-to- date inventories of hospital bed capacities for emergency admissions, and be able to ascertain blood supplies, types of ancillary equipment available, and other information to aid in the distribution of casualties. Using these communications links, either the dispatcher or the ambulance crew should notify the receiving hospital of the estimated arrival time of the ambulance and provide necessary information, including scaling when available, on the patient's condition to permit initiation of preparatory activities at the hospital when required. Patient Care in the Hospital Hospital-to-hospital communications may be used to obtain medical - consultation on a patient and to arrange for patient transfers between facilities* when such is dictated. All hospitals in an EMS system must *It is important that ambulances and hospitals have interchangeable, or compatible monitoring equipment, to ensure continuous monitoring during patient transfer. 32