EMS Then and Now
Modern emergency medical services generally evolved following the release of the “White Paper” in 1966. Realizing the erratic nature of care in this country, the document helped guide more standardized system development. Existing standards, if any, consisted of standard and advanced first aid training with additional knowledge and skills dependent on individual organizations.
This call to action resulted in the training and certification of emergency medical technicians. I first became certified as an EMT in 1971. The prerequisite for the course was standard and advanced first aid, which provided mostly hands-on skill training along with basic knowledge.
Those with a first aid background were especially adept at bandaging and splinting techniques. Of equal importance, the benefit of psychological first aid was taught. By the following year, the courses were combined and eventually lead to the norm, at that time, of an 81-hour class.
While there were a few advanced training programs being developed and operating at that time, modern paramedic training would develop over the next decade. Aside from a few better-known programs in cities such as Miami and Seattle, the first field unit in the United States to perform advanced prehospital care was Freedom House Ambulance in Pittsburgh. Anyone who is truly interested in the evolution of EMS should become familiar with their story of not only achievement but of overcoming diversity and eventually falling victim to their own success.
Decades later, paramedic training and care is widespread and so well publicized that it is an expected standard for much of the country. There are some definite benefits to advanced care in certain, but not all circumstances. The initials for paramedics were generally EMT-P; somehow this evolved into the simple term of paramedic. I never thought of that as a positive change.
In the beginning, well after the seventh day, the humble genesis of EMS included minimal diagnostic equipment. While a few services might have had access to some more advanced tools, usually a blood pressure cuff, stethoscope, penlight and a watch (really) were the basics. There were no field pulse oximeters, glucometers, 12-lead ECG units or other items that are now standards of care. Lacking those tools, care providers relied on and developed their senses, including common sense, to evaluate and care for patients.
When I managed a simulation center for a college of medicine, every room had a sign that read, “when in doubt, examine the patient.” In the 21st century, caregivers of all levels have grown up with ever-evolving technology. While that often provides the ability for more accurate diagnoses and treatments, it has yet to replace the need for a proper patient evaluation.
Many providers would start a scenario by requesting that certain tests be performed and then immediately expecting answers. They often would appear befuddled about what to do in the meantime. I have seen in action some super-providers who must possess x-ray vision as they were able to ascertain lung sounds without a stethoscope. Some folks will document distal pulses in all extremities without palpating them.
Pupils? They must be normal unless it is an overdose or death. Respirations? Pick your favorite number, usually 14, 16 or 18. Pulse rate? It must match the ECG; note that this does not usually work well in PEA. Oxygen saturation? 100%; it must be fine. Oh, wait; the patient was just removed from a house fire.
If you do not know where you are starting from, it is difficult to determine whether the care you are providing is beneficial, harmful, or not effective. There is a good reason to obtain an accurate initial assessment. Vital sign trends are at least as important as values. So while you are (hopefully) having a conversation with your patient about why you are present, and also (hopefully) obtaining a decent SAMPLE history, ensure that an accurate set of vital signs is being taken and recorded.
This should initially include a palpated pulse (radial present and regular or not, and rate), counted respirations, manual blood pressure (really) and auscultated lung sounds. Keep in mind that adventitious sounds such as rales are best found in the posterior bases; if your standard lung sounds are limited to a quick check of the upper anterior fields, it might be a little too late when you finally note the fluid congestion. Look at and listen to your patient; changes in appearance and mental status are often the first obvious signs of trouble.
Either during or after the initial vitals, additional tools such as monitoring and diagnostic cardiac tracings, pulse oximetry, capnography, glucometry and whatever else might be appropriate can be either helpful in confirming what you already suspect or help to narrow your differential diagnosis. They should not, however, serve as replacements for your initial hands-on assessment. The science of modern diagnostic equipment should coexist with the art of good patient assessment; they make a great team.
Good prehospital care may result from a combination of basic assessment and, when indicated, the use of more advanced techniques. Paramedics are generally considered clinicians while “technician” is literally part of the EMT title. The EMT-P title is a good reminder that inside of every good paramedic is a really good EMT.
Lew Steinberg, MPA, NRP, has been involved with EMS since 1971 and is still certified as a firefighter, paramedic, and instructor of many disciplines. He is a former fire chief and besides the prehospital environment has worked in both the emergency department and outpatient surgery settings. Reach him at ffpmlew@bellsouth.net.
