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Chapter 17 - Emergency Medical Services

Part 3 - Professional Services

Title Section
    Purpose 3-17.1A
    Policy 3-17.1B
    Background 3-17.1C
    Standards 3-17.1D
    Application of Standards 3-17.1E
    Definitions 3-17.1F
    Headquarters 3-17.2A
    Area Office 3-17.2B
    Service Unit 3-17.2C
    Pre-Hospital EMS Service 3-17.2D
    Support Responsibilities 3-17.2E
GENERAL 3-17.3
    Need for EMS 3-17.3A
    American Indian Needs for EMS 3-17.3B
    Response to Need 3-17.3C
    Organization 3-17.3D
    EMS Standards 3-17.3E
    EMS Systems 3-17.3F
    Medical Direction 3-17.3G
    EMS Program Integration 3-17.3H
    EMT & Active Labor Act Compliance 3-17.3I
    Goal 3-17.4A
    Objectives 3-17.4B

Exhibit Description
Manual Exhibit 3-17-F BIBLIOGRAPHY


  1. Purpose.  This chapter provides historical background, reference information, guidelines, and suggested resources for the provision of high quality emergency medical care to American Indian/Alaska Native (AI/AN) people.  This chapter revises Indian Health Service (IHS) policy regarding Emergency Medical Services (EMS).  The chapter may serve as an administrative handbook for individuals and organizations seeking to provide EMS services.  The actual provision of clinical care is not discussed in this chapter.
  2. Policy.  It is the policy of the IHS to operate directly or support the operation of tribal EMS programs with the expressed purpose of reducing the morbidity and mortality associated with emergent medical conditions.  The IHS will provide medical direction, when requested, to IHS and tribal EMS programs.  In addition the IHS will provide training and technical assistance to EMS programs in the form of continuing education for EMS providers and medical directors.
  3. Background.  The IHS has developed and improved the systems that provide EMS to AI/AN people in parallel with rapidly evolving national standards, but with recognition of special circumstances, such as the IHS redesign, and requirements of the population and areas served.
    1. Sources.  Emergency Medical Services are provided to AI/AN people by a wide variety of entities, including tribal ambulance services, tribal First Responder programs, tribal health departments, tribal fire departments, Community Health Representatives, and tribal hospitals and clinics; IHS ambulance services, IHS Hospitals, and IHS ambulatory care facilities; volunteer members of the public; and governmental or private non-Indian EMS organizations.  (See Manual Exhibit 3-17-C)
  4. Standards.  Each of the above entities has its own set of policies, procedures, medical direction, and administrative organization.  This chapter is intended to define the standards and responsibilities within the IHS EMS Program.
  5. Application of Standards.  The IHS encourages the various medical organizations that are involved in providing EMS to AI/AN people to:  
    1. Adopt the current standards contained in this Chapter for EMS systems, as well as local and/or state standards.  (See Manual Exhibit (3-17-B)
    2. Strive through policy, planning, funding, and implementation to meet these minimum standards.  (See Manual Exhibit 3-17-B)
    3. Use the current recommended standards to guide future development and improvement of EMS systems.  (See Manual Exhibit 3-17-B)
  6. Definitions.
    1. Emergency Medical Services System.  An EMS system is a comprehensive coordinated arrangement of resources and functions which are organized to respond in a timely staged manner to targeted medical emergencies, regardless of the cause of the emergency and the patients ability to pay, and to minimize the physical and emotional impact of the emergency.
    2. Stages of Emergency Medical Services Response.  Emergency Medical Service response stages include prevention, detection, notification, dispatch, pre-arrival, on-scene, transport and facility notification, emergency department/receiving facility, interfacility transport, critical care, inpatient care, rehabilitation, and followup.
    3. Out-of-Hospital Emergency Medical Care.  Out-of-hospital emergency medical care is emergency medical care provided to a patient in the pre-incident environment or during interfacility transport.
    4. Out-of-Hospital Emergency Medical Services Provider.  Out-of-hospital EMS providers are trained persons who provide emergency care at the site of the incident (injury or acute onset illness) and during transportation of the emergency patient from that site to an emergency room located in a hospital or clinic.  The term ?out-of-hospital EMS providers" includes First Responders and Emergency, Medical Technicians (EMT) at all certification levels (i.e., Basic, Intermediate, Paramedic, Instructor).
    5. Indirect (Off-Line) Medical Direction.  Indirect (off-line) medical direction includes but is not limited to training, quality improvement, dispatch, communication, protocol development and/or review, continuing medical education, direct medical direction (on-line medical control), critical incident stress debriefing, involvement in state and national EMS organizations, and research. Off-line medical direction is provided by a physician who has the overall responsibility for the medical aspects of out-of-hospital care.
    6. Direct (On-Line) Medical Direction.  The definition of direct (on-line) medical direction is clinical decision-making and issuance of medical orders to non-physician EMS providers who are in the act of providing direct care to patients.
    7. Advanced Trauma Life Support Course.  Advanced Trauma Life Support (ATLS) courses are standardized courses on trauma offered throughout the United States under the auspices of the American College of Surgeons.  The ATLS course content includes evaluation, treatment, stabilization, and transportation of critically injured trauma victims.
    8. Advanced Cardiac Life Support Course.  Advanced Cardiac Life Support (ACLS) courses are standardized courses on the treatment of cardiac emergencies offered throughout the United States under the auspices of the American Heart Association. Enrollment is open to physicians, nurses, physician assistants, nurse practitioners, and paramedics.  The course content centers on the evaluation and treatment of people with life-threatening cardiac problems.
    9. Trauma Nurse Certification Course.  Trauma Nurse Certification Course, (TNCC) courses are standardized courses on the treatment of the trauma patient.
    10. Pediatric Advanced Life Support.  Pediatric Advanced Life Support (PALS or APLS) courses are standardized courses on the treatment of pediatric emergencies.


  1. Headquarters.  The Director, Division of Clinical and Preventive Services (DCPS), Office of Public Health (OPH), is responsible for the EMS Program at the Headquarters level.  Specific Headquarters roles in EMS includes:
    1. Providing leadership and coordination of all aspects of the IHS EMS Programs.
    2. Formulating and developing IHS-wide EMS policies, procedures, standards and data collection systems, and consultation to Area programs.
    3. Providing liaison with and consultation to other IHS Headquarters staff, Area and Service Unit staffs, tribal officials, and other Federal and non-Federal agencies regarding EMS programs and activities.
    4. Providing a focal point for identifying and negotiating for EMS resources that can be available on a national level to AI/AN communities from Federal, state, and private organizations.
    5. Providing Area and program offices with resource manuals and other EMS materials to facilitate current knowledge in this evolving field.
  2. Area Offices.  The Area Director is responsible for EMS at the Area level.  Specific Area EMS roles include:
    1. Assign primary responsibility of EMS program coordination to a designated EMS coordinator who will serve as the principal point of contact within the Area office for EMS issues.
    2. Assuring that clinical EMS services are of proper quality, consistent with recognized patient care standards, and provided in an ethical fashion with respect for the dignity of each patient.
    3. Ensuring that health care professionals in IHS emergency facilities are adequately trained to provide clinical EMS Services.
    4. Assisting in the planning and monitoring (including oversight and evaluation) of the quality, appropriateness, and effectiveness of emergency medical care.
    5. Overseeing the establishment and implementation of EMS medical control plans and treatment protocols throughout the Area.
    6. Coordinating the Area EMS program including policy and program development, field consultation, liaison with Headquarters and Department of Health and Human Services (HHS) Regional Offices, pursuit of outside resources, planning and implementing training programs, negotiations and administration of contracts for services, and evaluation of field programs.
    7. Providing indirect medical direction to the Area EMS program, with primary responsibility for maintaining integrity, quality, and effectiveness of EMS patient care activities within the Area.
    8. Assisting with the resolution of EMS medical issues which cannot be resolved directly at the Service Unit level.
    9. Providing proper application of medical care quality improvement activities concerning EMS.
  3. Service Unit.  The Service Unit Director (SUD) is responsible for EMS at the Service Unit level.  The SUD delegates these responsibilities to the Service Unit Clinical Director and EMS Medical Director.  Specific Service Unit responsibilities include:
    1. If the Service Unit provides medical direction to an IHS or tribal EMS program, the SUD will designate an individual as the EMS Medical Director.
    2. The position of EMS Medical Director will be defined in the medical staff by-laws of the Service Unit.
    3. Developing, recommending, implementing, and evaluating, the policies and procedures for the EMS program at the Service Unit.
    4. Coordinating EMS activities with other Service Unit programs.
    5. Providing Service Unit input into community planning, organizing, and administering of EMS systems.
    6. Working with tribal EMS programs, Public Safety/Law Enforcement personnel, and criminal investigations to provide smooth patient transition through the emergency room.
    7. Serving as a member of the Community EMS Organization.
  4. Pre-Hospital Emergency Medical Services Service.  All aspects of the organization and provision of EMS require the active involvement and participation of physicians.  These aspects include the design, continued revision, and operation of the system from initial access, to pre-hospital contact and treatment, through stabilization in the Emergency department, to transfer to definitive care and followup.
    1. Emergency Medical Service Medical Director.  The EMS Medical Director must be a physician who is responsible for the EMS system and the quality of care delivered by it.
    2. Emergency Medical Service Medical Director Duties.
      1. The Medical Director must be active in planning and implementing training for pre-hospital providers, medical dispatchers, nurses, and physicians involved in the EMS system.  This includes initial training, continuing medical education, and certification and re-certification training requirements.
      2. The Medical Director should actively promote and participate in community education concerning the EMS system.
      3. The Medical Director should be actively involved with Service Unit Community Injury Control staff and activities.
      4. The Medical Director is to develop and maintain an active quality improvement program to include but not limited to:
        1. Pertinent ambulance run reviews.
        2. Review of all deaths and cardiac arrests.  This page is replicated see U:Decker.ems\Page 6n7.wpd. Pls replace.
        3. Review of all advanced pre-hospital skills (i.e., intubation, IVs, needle chest decompression).
        4. Evaluation of response times and scene times.
        5. Participation in state or local trauma registry if available; otherwise, maintain pertinent trauma data that will assist in improvement of care.
        6. Monitor dispatch functions.
        7. Monitor quality of direct (on-line) medical control.
      5. The Medical Director is expected to be in the field at regular intervals to enhance his or her own pre-hospital experience and to allow direct observation of pre-hospital care.  This is fundamental to assuring quality.
      6. The Medical Director ensures that EMS policies and procedures and pre-hospital Protocols/Standing Orders are developed utilizing peer-reviewed published data, established principles and guidelines.  Review and revision should occur on a regular basis.
      7. The Medical Director should be active in local, state, regional, and national EMS organizations.
      8. The Medical Director should be active in local disaster preparation.
      9. The Medical Director is responsible for preparing written status reports as required.  Reports are submitted to the Clinical Director for review and distribution to appropriate personnel or agencies.
      10. The Medical Director should be provided with appropriate training in EMS medical direction and sufficient time to perform the duties of the EMS Medical Director.
    3. Emergency Medical Service Director or Ambulance Service Director.  The EMS Director or the Ambulance Service Director is responsible for the implementation and provision of EMS services.  The EMS Director's responsibilities include:
      1. Developing policies and procedures covering EMS operations.
      2. Assuring that EMS services provided are of proper quality and consistent with recognized standards of care.
      3. Coordinating the delivery of EMS services with health facility staff.
      4. Evaluating EMS services.
      5. Assuring that appropriate training is available to maintain skills of EMS providers.
  5. Support Responsibilities.  All 14 attributes of an EMS system must be adequately addressed in the successful development of EMS systems that serve AI/AN people.  Several of these attributes (training, communications, and transportation) are critical to the successful development and improvement of EMS capabilities.  (See Manual Exhibit 3-17-D.)  The IHS assists AI/AN EMS programs with these attributes and with program development and improvement in general, directly or through partnerships with other organizations.
    1. Emergency Medical Services Training
      1. The IHS EMS Training Coordinator develops, monitors, and conducts training activities for EMS out-of-hospital providers.
      2. Out-of-hospital provider training includes initial and refresher courses for First Responder, Cardiopulmonary Resuscitation (CPR), and EMT at all levels (Basic, Intermediate, Paramedic, and Instructor).
      3. System Management Training includes Ambulance Program and Emergency Room administration skills and coordination.
      4. Professional competency will be emphasized, developed, and maintained through use of such accepted training programs as Basic Life Support, ACLS, and ATLS, where appropriate.
      5. The IHS will organize and offer an annual EMS Medical Direction Course.
    2. Mountain Plains Health Consortium.
      1. The Mountain Plains Health Consortium (MPHC), includes the Black Hills Training Center (BHTC) in the Aberdeen Area, IHS, the Cooperative Health Education Program of the Department of Veterans Affairs (VA), and the Health Education Development System, Inc., a 501-C-3 nonprofit corporation.
      2. Resources and mandates flow from the IHS to MPHC through an interagency agreement with the VA.  Specifically, the agreement is with the VA Black Hills Health Care System.
      3. Included with BHTC resources assigned to MPHC is the IHS EMS Training Coordinator, with responsibilities as listed in 17.2 E.(1) above.
      4. The MPHC will work closely with the IHS Headquarters officials to provide a full range of technical and other support activities for EMS activities at the national level.
      5. The MPHC will work closely with the National Native American Emergency Medical Services Association (NNAEMSA) in accomplishing its goals.
    3. National Native American Emergency Medical Services Association.
      1. The NNAEMSA is an independent, intertribal organization established to provide both educational and technical support for its members.
      2. Both IHS Headquarters and MPHC will work closely with NNAEMSA to strengthen the organization and expand its capabilities.
      3. The role of NNAEMSA will be evolutionary in nature, but is intended to provide the leadership in meeting the educational and technical support needs of EMS providers serving AI/AN people.

3-17.3  GENERAL

  1. Need for Emergency Medical Services.  The inability to respond immediately and effectively to an emergency medical crisis has been recognized as a major deficiency of the health care system in many communities of the nation, including many AI/AN communities.  Recognizing the national need for improved services, the Congress enacted the Highway Safety Act of 1966, which specifically addressed the need to improve EMS related to highway accidents.  Further Federal stimulus came from the "EMS Systems Act of 1973, Public Law (P.L.) 93-154, as amended by the "EMS Amendments of 1976," P.L. 94-573.  These Acts were administered by the United States (U.S.) Department of Health, Education, and Welfare and are currently administrated by its successor organization the HHS.  These Acts promoted development of comprehensive regional EMS systems and authorized grants for that purpose.  Most recently, the National Highway Traffic Safety Administration (NHTSA) has redefined the former ?components? of EMS as the 14 EMS Attributes in the "EMS Agenda for the Future."  (See Manual Exhibit 3-17-E.)
  2. American Indian Needs for Emergency Medical Services.  The most common cause of death for Indian people is diseases of the heart.  The most common cause of death for Indian people under the age of 44 years is intentional and unintentional injuries.  Victims of both heart disease and injuries routinely need access to EMS services if they are to survive.  Each year, the IHS and tribal EMS programs make over 60,000 runs to provided much needed care in extremely remote locations.  Reservations are usually characterized as rural or frontier areas.  Provision of effective EMS services in rural communities is difficult due to problems imposed by available resources, physical constraints of isolation, sparse population, and topographical/climate conditions.  These conditions add a significant element of complexity in providing adequate EMS to AI/AN populations.
  3. Response to Need.  Despite such difficulties, Indian communities have demonstrated their interest and commitment to the establishment and operation of such systems.  They have turned to the IHS and other organizations for medical, technical, and financial leadership to build effective and efficient programs.  (See Manual Exhibit 3-17-C.)  As a result, the EMS program was institutionalized in 1978 within the Office of Health Programs in the IHS.  Currently, EMS is a program within the DCPS, OPH, IHS.  There are approximately 70 tribal and 2 IHS EMS Programs.  These programs were founded to addresses the need for EMS services in AI/AN communities.
  4. Organization.  The EMS program is largely tribally managed at the service delivery level.  Within the IHS, EMS components exist at the Headquarters, Area, and Service Unit levels.  At the Headquarters level, EMS responsibility falls within the DCPS, OPH.  National Medical Direction and National EMS training functions are carried out by staff assigned to field locations.
  5. Emergency Medical Services Standards.  Individual EMS programs that serve AI/ANs will comply with state and national EMS standards.
  6. Emergency Medical Services Systems.  Individual EMS programs that serve AI/ANs will be comprehensive EMS systems as defined in DEFINITIONS above and Manual Exhibit 3-17-E, the "EMS Agenda for the Future."
  7. Medical Direction.  Because the standard of care for EMS requires medical direction for all levels of EMTS, the involvement of a licensed physician knowledgeable in EMS is required for all IHS or tribal EMS program.
  8. Emergency Medical Services Program Integration.  Individual EMS programs that serve AI/ANs will be integrated with regional and state systems to the maximum extent possible with all health care services.  This will help ensure that the care provided by EMS does not occur in isolation.  (See Manual Exhibit 3-17-C.)
  9. Emergency Medical Treatment and Active Labor Act Compliance.  Any IHS facilities which bill for treatment of Medicare or Medicaid patients will comply with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA).


  1. Goal.  The goal of the IHS EMS Program is to provide leadership and assistance to AI/ANs for the development of comprehensive EMS systems which will improve the quality of patient care and reduce morbidity and mortality.  Efforts made toward this goal will include involvement with injury prevention programs such as community injury control and substance abuse programs.
  2. Objectives.
    1. The IHS will assist in the development of and participation in comprehensive regionalized EMS systems for AI/AN people.
    2. The IHS will assist in the design of programs and systems to:
      1. Educate the population in methods of reducing risk factors, preventing accidents, proper response to emergency situations, and proper and efficient utilization of EMS by the public (for example:  The Bystander Care Program).
      2. Assure adequate training of large segments of the community in Basic Life Support measures.
      3. Reduce the time interval between onset of an emergency and the delivery of life support services through the EMS system.
      4. Provide emergency care by well-trained providers including First Responders, EMTs, nurses, nurse practitioners, physicians, and physician assistants.
      5. Provide readily available and accessible emergency services for stabilization and treatment of emergency patients at the scene.
      6. Provide for rapid and effective transportation of emergency patients to appropriate medical facilities according to specific treatment, triage, and transportation protocols.
    3. The IHS will define the roles of hospital staff and provide for adequate equipment, facilities, and training in IHS Emergency Departments.
    4. The IHS will encourage high quality emergency care using appropriate systems of professional review, licensure, certification, quality improvement, community involvement, and responsiveness to needs of the population served.
    5. The IHS will ensure that EMS training programs are available to train out-of-hospital medical personnel, EMS medical directors, and physicians and nurses who provide care for emergency patients.
    6. The IHS will encourage tribal management of EMS out-of-hospital and facility-based portions of EMS systems including system finance i.e., third party billing.
    7. The IHS will verify availability of high-level emergency care through contract facilities.

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