Emergency Medical Service (EMS) is a branch of emergency services dedicated to providing out-of-hospital acute medical care and/or transport to definitive care, to patients with illnesses and injuries which the patient, or the medical practitioner, believes constitutes a medical emergency. The goal of emergency medical services is to either provide treatment to those in need of urgent medical care, with the goal of satisfactorily treating the malady, or arranging for timely removal of the patient to the next point of definitive care. This is most likely a Casualty at a hospital or another place where physicians are available. The term Emergency Medical Service evolved to reflect a change from a simple transportation system (ambulance service) to a system in which actual medical care occurred in addition to transportation. In some developing regions, the term is not used, or may be used inaccurately, since the service in question does not provide treatment to the patients, but only the provision of transport to the point of care.
In most places in the world, the EMS is summoned by members of the public (or other
emergency services, businesses or authority) via an emergency telephone number which puts
them in contact with a control facility, which will then dispatch a suitable resource to deal with
the situation.
In some parts of the world, the term EMS also encompasses services developed to move
patients from one medical facility to an alternative one; inferring transfer to a higher level of
care. In such services, the EMS is not summoned by
members of the public but by clinical professionals (e.g.
physicians or nurses) in the referring facility. Specialized
hospitals that provide higher levels of care may include
services such as neonatal intensive care (NICU), pediatric
intensive care (PICU), state regional burn centres,
specialized care for spinal injury and/or neurosurgery,
regional stroke centers, specialized cardiac care (cardiac
catherization), and specialized/regional trauma care.
In some jurisdictions, EMS units may handle technical rescue operations such as extrication,
water rescue, and search and rescue. Training and qualification levels for members and
employees of emergency medical services vary widely throughout the world. In some systems,
members may be present who are qualified only to drive the ambulance, with no medical
training. In contrast, most systems have personnel who retain at least basic first aid certifications, such as Basic Life Support (BLS). Additionally many EMS systems are staffed
with Advanced Life Support (ALS) personnel, including paramedics, nurses, or, less commonly,
physicians.
The most basic emergency medical services are provided as a transport operation only, simply
to take patients from their location to the nearest medical treatment. This was often the case in
a historical context, and is still true in the developing world, where operators as diverse as taxi
drivers and undertakers may operate this service. Most developed countries now provide a
government funded emergency medical service, which can be run on a national level, as is the
case in the United Kingdom, where a national network of ambulance trusts operate an
emergency service, paid for through central taxation, and available to anyone in need; or can be
run on a more regional model, as is the case in the United States, where individual authorities
have the responsibility for providing these services.
Some countries closely regulate the industry (and may require anyone working on an
ambulance to be qualified to a set level), whereas others allow quite wide differences between
types of operator.
1) Government Ambulance Service – Operating separately from (although alongside) the
fire and police service of the area, these ambulances are funded by local, provincial or
national government. In some countries, these only tend to be found in big cities,
whereas in countries such as U.K., almost all emergency ambulances are part of a
national health system.
2) Fire or Police Linked Service – In countries such as the U.S.A., Japan, and France;
ambulances can be operated by the local fire or police service. This is particularly
common in rural areas, where maintaining a separate service is not necessarily cost
effective. In some cases this can lead to an illness or injury being attended by a vehicle
other than an ambulance, such as a fire truck.
3) Volunteer Ambulance Services – Charities or non-profit companies operate
ambulances, both in an emergency and patient transport function. They may be linked to
a voluntary fire service, with volunteers providing both services. There are charities
which focus on providing ambulances for the community, or for cover at private events
(sports etc.). The Red Cross provides this service across the world on a volunteer basis
(and in others as a Private Ambulance Service). These volunteer ambulances may be
seen providing support to the full time ambulance crews during times of emergency. In
some cases the volunteer charity may employ paid members of staff alongside
volunteers to operate a full time ambulance service, such in some parts of Australia,
Ireland and most importantly Germany and Austria.
4) Private Ambulance Service – Normal commercial companies with paid employees, but
often on contract to the local or national government. Private companies may provide
only the patient transport elements of ambulance care (i.e. non urgent), but in some
places, they are contracted to provide emergency care, or to form a 'second tier'
response, where they only respond to emergencies when all of the full-time emergency
ambulance crews are busy. This may mean that a government or other service provide
the 'emergency' cover, whilst a private firm may be charged with 'minor injuries' such as
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cuts, bruises or even helping the mobility impaired if they have for example fallen and
just need help to get up again, but do not need treatment. This system has the benefit of
keeping emergency crews available all the time for genuine emergencies.
5) Combined Emergency Service – these are full service emergency service agencies,
which may be found in places such as airports. Their key feature is that all personnel are
trained not only in ambulance (EMT) care, but as a firefighter and a peace officer (police
function).
6) Hospital Based Service – Hospitals may provide their own ambulance service as a
service to the community, or where ambulance care is unreliable or chargeable. Their
use would be dependent on using the services of the providing hospital.
7) Company Ambulance - Many large factories and other industrial centres, such as
chemical plants, oil refineries, breweries and distilleries have ambulance services
provided by employers as a means of protecting their interests and the welfare of their
staff. These are often used as first response vehicles in the event of a fire or explosion.
Emergency Medical Service is provided by a variety of individuals, using a variety of methods.
To some extent, these are determined by country and locale, with each individual country
having its own 'approach' to how EMS should be provided, and by whom. In some parts of
Europe, for example, legislation insists that efforts at
providing Advanced Life Support (ALS) services must be
physician-led, while others permit some elements of that
skill set to specially trained nurses, but have no
paramedics. Elsewhere, as in North America, the UK and
Australia, ALS services are performed by paramedics, but
rarely with the type of direct "hands-on" physician
leadership seen in Europe. Increasingly, particularly in the
UK and in South Africa, the role is being provided by
specially-trained paramedics who are independent
practitioners in their own right.
Generally speaking, the levels of service available will fall into one of three categories; Basic
Life Support (BLS), Advanced Life Support (ALS), and in some jurisdictions, a Intermediate Life
Support (ILS), which is essentially a BLS provider with a moderately expanded skill set, may be
present, but this level rarely functions independently, and where it is present may replace BLS
in the emergency part of the service. When this occurs, any remaining staff at the BLS level is
usually relegated to the non-emergency transportation function.
While designing an Emergency Medical Service, the essential decision in pre-hospital care is
whether the patient should be immediately taken to the hospital, or advanced care resources
are taken to the patient where they lie. The "scoop and run" approach is exemplified by the
MEDEVAC aero-medical evacuation helicopter, whereas the "stay and play" is exemplified by
the French and Belgian SMUR emergency mobile resuscitation unit. The strategy developed for
pre-hospital trauma care in North America is based on the Golden Hour theory, i.e., that a
trauma victim's best chance for survival is in an operating room, with the goal of having the patient in surgery within an hour of the traumatic event. This appears to be true in cases of
internal bleeding, especially penetrating trauma such as gunshot or stab wounds. Thus, minimal
time is spent providing pre-hospital care (spine immobilization; "ABCs", i.e. ensure airway,
breathing and circulation; external bleeding control; endotracheal intubation) and the victim is
transported as fast as possible to a trauma centre.
