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Journal of the Academy of Hospital Administration

Emergency Medical Technicians in the New Millennium

Author(s): Satpathy S

Vol. 11, No. 2 (1999-07 - 1999-12)

Keywords : Emergency, Medicine, Technicians

Introduction:

Developing countries, especially those which have achieved some degree of industrialization are gradually becoming interested in "Emergency Medicine" as a specialised area of medical care, due in part to the "epidemiologic transition" of disease patterns in which a country's economy influences the development of "manmade" diseases including injuries, cancers and cardiovascular diseases. It has been estimated that injuries are the leading cause of premature death in adults, as measured on the basis of potential years of life lost1. This underlines the need for development of a potentially viable system which co-ordinates the multifarious agencies involved in the various aspects of emergency medical care2. Emergency Medical Services (EMS) is an important component of acute medical care provided by the hospital, and is expected to serve the community during any time of its need at any hour of the day. In this context, "Medical Emergency" is defined as a "situation when patient requires urgent and high quality medical care to prevent loss of life and limb and initiate action for restoration of normal healthy life".

The magnitude of trauma cases is mammoth and it claims about 3.5 million lives annually all over the world, making it one of the leading causes of death in developed countries. In the developing countries it is inching its way upwards amongst the prime causes of mortality ; with one road traffic accident every 4 minutes; and about 350 accidents/day occuring in our country. The scenario is equally bleak in the capital where the deadly roads and killer "Blue lines" claim 7-8 lives every day. In the last decade the number of fatal accidents/road deaths has increased by 74% to reach 2176 in 19973.

The development of Emergency Medical Care in India started way back in November 1963, during the Central Council of Health meeting which urged all State Governments to set up emergency medical service in all major cities and towns. Thereafter, a number of committees viz. Jain Committee (1968), Rao Committee (1968), Siddhu Committee (1978), Ad hoc Committee for CATS (1984), Balu Sankaran Committee (1994) and Ramesh Chandra Disaster Relief Committee (1996) have exposed the glaring loopholes in the primitive emergency medical service that exists in India; and have recommended development of a cadre of professionals (paramedics) to augment and bolster the "pre hospital component" of emergency medical care.

A review of available literature in last few decades has proven beyond doubt the efficacy of providing basic pre-hospital care to accident and emergency victims. Frey and Huelke4 studied that resuscitation and survival in motor vehicle accidents is drastically improved with quick medical treatment. Hudson and Cowley5 reported a three fold increase in mortality for every thirty minutes delay in the start of treatment. Hofman6in 1976 found that 35.8% incidence of preventable complications can be managed by emergency medical technicians. Thygerson7reported that 25% of permanently disabling accidents would not have been crippling if proper medical treatment had started in time. Eisenberg MS et al8,9 in a number of studies have demonstrated that early defibrillation is the most important single medical intervention for out of hospital cardiac arrests due to ventricular fibrillation. Recently Simmons et al10 found that standard out of hospital triage criteria benefit from inclusion of advanced emergency medical technicians injury severity perception information.

Emergency Medical Technicians:

In developed countries there are various categories of EMT's who have undergone training

  • to acquire and hone various skills viz.
  • Category Skills required for functioning
  • EMT-B (Basic)

Assessment, Extrication, Splinting and Bandaging, Airway management with oral/nasal airway, CPCR, PSAG/MAST application.

  • EMT-A (Ambulance) EMT-B skills + Driving lessons + Ambulance operations including legal responsibilities.
  • EMT-I (Intermediate) EMT-B skills + Shock management + IV therapy + Trauma evaluation + Pre-hospital/triage according to established Protocols.
  • EMT-D (Defibrillation) EMT-B skills + use of manual/semiautomatic/automatic defibrillator; recognition of VF pattern i.e development of cognitive skills.
  • EMT-Paramedic EMT-I skills + insertion of endotracheal tubes, administration of emergency medications + can act as assistants of physicians + ALS skills.

On the contrary, in our country there is no standardised course curriculum for emergency medical technicians, other than St. John's Ambulance Services which only has a certificate course in first aid. Keeping in view the tremendous requirement of EMT's it is proposed to have training in a medical school environment which has been successfully tried out at various places in USA11,12.

Proposed Course Curriculum for E.M.T.(Basic)

Salient features are as follows:

Target Audience:

  • Hospital/Health Care Workers.
  • First year medical students.
  • Nurses posted in EW/ER.
  • Allied personnel : Police, fireguards, life guards etc.

Prerequisities:

  • High degree of motivation.
  • No physical disability.
  • Adequate spare time (20-40 hrs work time/week).
  • No police cases/criminal cases (last 12 months).
  • Should have completed 40 hrs First Aid Course.

Course description :

  • AIM to provide technical training in pre-hospital stabilisation and rapid transport of emergency patients to hospitals.
  • Length (Duration)- 3 weeks; (120 hours).
  • Method : Didactic presentations; development of psycho motor skills, communication with patients, attendants, doctors.
  • Upon successful completion - candidates take National Registry of E.M.T exams.

Course attendence :

  • Mandatory to attend all classes.
  • 4 or >4 classes missed liable for expulsion.
  • If >10 min late, admitted at 1st break (max 3 times during course).

Dress codes :

  • Class room : uniform as prescribed.
  • Clinicals (uniform strictly adhered to)
    • Light blue oxford style shirt without patches/insignia.
    • Navy blue trousers, black shoes, belts, dark jackets.
    • use of "torniquets" and PASG/MAST should be understood well, indications and cautions, should be drilled thoroughly.
  • Ventilation : Oxygen powered ventilation devices are useful.
    • New redesigned-" flow restricted- Oxygen powered ventilation" device is a must, to be known properly.
    • It is fairly easy for one person to ventilate a patient.
    • A welcome tool in the armamentarium especially for rural areas from where distances to hospitals are great.

Proposed Course Curriculum for E.M.T-A (Ambulance)

Salient features are as follows :

  1. Target audience : same as EMT-B course.
  2. Prerequisites : same as EMT-B course.
  3. Course attendance : same as EMT-B course.
  4. Dress codes : (both class room & clinicals) same as EMT-B course.
  5. Course description:
    • AIM to provide technical training in pre hospital stabilisation and rapid transport of emergency patients to hospitals.
    • Length (duration) : (a) Regular : 6 months for Theory & Lab + Clinicals. (b) Accelerated : 4 months for Theory & Lab+Clinicals.
    • Method : Didactic presentations; development of driving, communication and psychomotor skills needed in job.
    • After successful completion, candidates take should the qualifying examinations.
    • Grading : 3 grades A,B,C ; proper weightage to unit exams, home work and final exams.
  6. Course contents (curriculum):
  • EMT A - 1. Theory - (5 domains).
  • Laboratory Practicals.
  • Hospital Practicum.
  • Ambulance Practicum.
  • Driving Program.

1. THEORY : Consists of 5 domains

A. Domain One

  • Primary survey.
  • Critical interventions.
  • Transport and triage decisions.
  • Secondary survey and patient history documentation.

B. Domain Two

  • C.P.R. in adults.
  • Anatomy and physiology of humans.
  • Medical emergencies.
  • Shock.

C. Domain Three

  • Musculo - skeletal injuries/trauma.
  • Soft tissue injuries.
  • Burns.
  • Environmental injuries/emergencies.

D. Domain Four

  • Obstetrical and genitourinary emergencies.
  • Paediatric emergencies.
  • Geriatric emergencies.
  • Interhospital transfers.

E. Domain Five

  • Didactic introduction to driving ambulance.
  • Ambulance operations.
  • Legal responsibilities and rights.

2. Laboratory Practicals:

* Tried out and tested in "scenario format" using other classmates in simulated trauma and medical situations with a system which effectively co-ordinates the multifarious agencies dealing with-emergencies.

References:

  1. Philips M, Feachem RGA, Murray CJL et al; Adult health; A legitimate concern for developing countries. American Journal of Public Health 1993; 83; 1527-30.
  2. Sklar DP. Emergency medicine and the developing world. American Journal of Emergency Medicine 1998; 319;918-24.
  3. Madhukar K. Accident rate up, not down. The Hindustan Times 1997 Dec-25; P3; (col. 5-6).
  4. Frey S, Huelke DF, Gikas, PW. Resuscitation and survival in motor vehicle accidents. Journal of Trauma, 1969; 9; 292.
  5. Hudson F, Cowley RA, Scanlan E et al. An economical and proved helicopter program for transporting the emergency critically ill and injured patient in Manhattan. Journal of Trauma 1973; 13; 1029-38.
  6. Hofman E. Mortality and morbidity following Road Accidents. Annals of Royal College of Surgeons, Eng. No. 58, 1976.
  7. Thygerson AL. Accidents and disasters. Prentace Hall Inc. New Jersey 1972.
  8. Eisenberg MS, Cummins RO. Defibrillation performed by the emergency medical technican. Circulation, Dec 1986; 74 (Supp IV); 9-12.
  9. Eisenberg MS. et al. Treatment of ventricular defibrillation; Emergency Medical technicians defibrillation and paramedic services. JAMA 1984; 251; 1723-9.
  10. Simmons E et al. Paramedic Injury severity perception can aid trauma triage. Annals of Emergency Medicine, Oct 1995; 26 (4); 461-8.
  11. Watkins GM, Metcalf GN, Andette LG. Emergency Medical technician (EMT-A) trg. in a medical school environment. 1975; 15 (9); 772-8.
  12. Bradley K, Anwar RA; Davidson SJ, Manand T. A time efficient EMT-A course for Ist year medical students. Annals of Emergency Medicine Sep 1982; 11(9); 478-81.

*Asstt. Professor, Department of Hospital Administration, AIIMS, N. Delhi 110 029

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