7 The emergency medical system

The mission of the emergency medical services is to promote and support a system that provides timely, professional, and state-of-the art emergency medical care, including ambulance services, to anyone who is victim of a sudden injury or illness, at any time or location and at any phase of the emergency incident. These phases include lay people’s prevention and preparedness, occurrence of the problem, its detection, alarming of trained responders, help provided by bystanders and trained pre-hospital providers, transport to the appropriate hospital, and, if necessary, admission or transfer to a more appropriate hospital. In order to meet the goal outlined, emergency medical services must work closely with local and state officials—fire and rescue departments, other ambulance providers, hospitals, and other agencies—to foster a smooth functioning network. The term emergency medical services evolved to reflect a change from a simple system of ambulances, providing only transportation, to a system in which actual medical care is given at the scene and during transport. Medical supervision and/or participation of emergency medicine physicians in the emergency medical services systems contribute to the quality of medical care. This emergency medical services network must be capable of responding instantly and reliably around the clock, with well-trained, well-equipped personnel linked, as needed, through a strong communication system. Research plays an important role in conserving resources and improving the delivery of health care. This chapter gives an overview of the different aspects of emergency medical services and calls for high-quality research in pre-hospital emergency care in a true partnership between cardiologists and emergency physicians.

Most European countries have a system for pre-hospital emergency medical service (EMS) which is a component of the pre-hospital emergency health care system. EMS provides treatment to those in need of urgent medical care, with the goal of satisfactorily treating the presenting conditions or arranging for timely removal of the patient to the next point of appropriate care—this is most likely an ED at a hospital. Time-sensitive, life-threatening illnesses and injuries are among the leading causes of morbidity and mortality. However, professional standards, organizational structures, and coordination vary widely across the European Union (EU).

In most countries, the EMS also encompasses the role of moving patients from one medical facility to another one, usually to facilitate the provision of a higher level or more specialized field of care (‘upgrade’), but also to transfer patients from a specialized facility to a local hospital or nursing home when they no longer require the services of that specialized hospital such as following successful cardiac catheterization due to MI (‘downgrade’). 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. However, for patients in need of urgent care, recognition of the urgency and availability to alarm and activate an EMS system is crucial.

An essential decision in pre-hospital care is whether the patient should be immediately taken to a hospital or advanced care resources taken to the patient. The ‘scoop and run’ approach is the pure transport modality, whereas the ‘stay and play’ is exemplified by the French and Belgian SMUR emergency mobile resuscitation unit or the German ‘Notarzt’ system (preclinical emergency physician). Traditionally, it was sometimes simplified to the Anglo-Saxon or Germano-French system.

Although each EMS share common grounds, it is important to recognize potential differences. EMS is provided by a variety of individuals, using a variety of methods. To some extent, these will be determined by each individual country. Beyond the national model of care, the type of EMS will be determined by local jurisdictions and medical authorities, based upon the needs of the community and the economic resources to support it. While there is no unique EMS standard in the EU, it is difficult to benchmark EMS systems and to identify meaningful performance indicators for outcome.

The basic goal is that, for patients in need of urgent care, the therapeutic-free interval remains as short as possible and all interventions at the scene or during transport must reduce mortality, morbidity, or invalidity. Before treatment, basic medical history and examination, and diagnostic tests (e.g. standard 12-lead ECG) may be needed and should be performed.

From a historical perspective, initially, the focus was on the acute care of trauma patients [1]. Removal at the incident scene was important and included technical rescue operations such as extrication, rescue out of a building, water rescue, etc. Subsequently, critically ill patients came in the picture, and, in the late nineties, one began to recognize the importance of optimal EMS systems for the improvement of the health status of a population [2].

The EMS system can be conceptualized in different ways. One way is by response area (e.g. urban, suburban, rural, or mixed) or by identifying the organizational type or provider of the EMS system (e.g. community non-profit agency, fire-based agency, governmental service-based agency, hospital agency, private non-hospital-based agency). Another way is by describing potential stakeholders: users, providers, and processes. This section will focus on patients, callers, dispatching system, ambulance system, and hospitals (see Figure 7.1).

The population covered by the EMS system can be described by population characteristics (e.g. population density, average income), health indices (e.g. life expectancy, infant mortality rate, maternal mortality rate), or leading causes of death (e.g. heart disease, cancer, cerebrovascular disease). It is important to describe these patient characteristics to allow meaningful comparisons between EMS systems and to produce strategies to improve pre-hospital care. Socio-demographic characteristics are important in general health care, and even more so for potential EMS users. There may be a considerable variability in socio-demographic characteristics between countries, but also between regions within one country. In addition, patients with specific socio-demographic characteristics may not want to access the EMS system and may use alternative ways to enter the health care system in case of an acute event.

The caller is a person that alarms the EMS system and judges that a potential patient needs emergency medical care. The caller, with or without any relationship with the potential patient, can be: the patient himself, a family member, a layperson, or a medical professional. Two elements may trigger the caller to contact the EMS system: the recognition of the urgency and the confidence that the EMS system will provide an adequate response. To educate a population to recognize symptoms of urgencies and emergencies is a long-lasting educational task. This subject is often neglected in educational programmes but critical to improve outcome of pre-hospital care. The general population is not knowledgeable about typical symptoms of common diseases needing urgent care. Many non-medically trained people (lay) do not recognize the key symptoms of common cardiovascular emergencies such as ACS and stroke. To induce confidence in a system is an even more difficult task. Even in countries with an efficient EMS system, patients are still too often brought to hospital by using alternative ways of transportation. The factors influencing the caller are multifaceted but imperative to be recognized and addressed if the system is not alerted frequently for clear indications.

Calls to the EMS system should be transferred as soon as possible to a trained dispatcher able to make a layered response using an appropriate emergency dispatch system. This response focuses on the allocation of appropriate human resources and equipment to anyone who urgently asks for medical help. Consequently, optimal emergency medical dispatching (EMD) implies that the level of care provided matches the medical needs of all problems reported to the dispatching centre (triage). EMD also includes: the provision of accurate instructions to the caller before pre-hospital care providers arrive (e.g. telephone-assisted CPR), the attribution of the right pre-hospital team to the right patient, the selection of the most appropriate hospital for definitive medical care, and, in case of disaster, the necessary coordination (see Table 7.1).

For the EU, 112 is the emergency telephone number which allows European citizens in distress to contact the emergency services in all member states. A national emergency number should speed up the process and guarantee that all relevant agencies are warned and involved. However, while the unique European number is promoted, there remain at least ten different telephone numbers for urgent medical care. In addition, there is ongoing debate about whether the dispatching response on a 112 call should be discipline-specific or be provided through a centralized reception regardless of the type of request (e.g. medical, police, firefighters). The system with a universal centralized call-taker has advantages concerning the optimal management of all calls. However, this can take time, and potentially life-threatening seconds can be lost. There are various ways of operating EMD systems. The essential elements which have been identified are the use of standard protocols, the need for medical supervision, an audit of operations, and the training of dispatchers [3]. A unique medical dispatching number exclusively dedicated to this function would facilitate pre-hospital care.

Two important determining elements in medical dispatching are the available means and medical needs. The case mix of incoming calls differs significantly between countries, but also between regions within countries. Even an abuse of the unique number to obtain information can be significant and ‘distracting’ from the real urgent calls. The available means depend on the qualification of the team and the number of teams available. In some countries, a regulation exists that defines the minimal number of available teams per 100 000 inhabitants. However, the fluctuation of available teams between day and night, and week or weekend may be significant and jeopardize a potentially appropriate medical dispatching. The case mix of incoming calls and the (specific) teams available are factors to be studied in each medical dispatching centre.

Beside the determining elements, the analytic capacities of the dispatcher are overestimated. The caller communicates under stress, providing limited information in any language. To standardize the responses and help the dispatcher, predetermined decision-making algorithms are defined and can help to determine the most appropriate response. Medical regulation, as in France, is an option to improve EMD. However, the impact of medical regulation on the improvement of the health status of a population has never been proven.

In modern medical dispatching, a computerized system which promotes the call-taker, records responses, supports decision-making, and provides information for audit and quality assurance is considered essential [3, 4]. Computer-aided medical dispatching is becoming standard. New dispatching technologies, such as caller identification, caller place identification, GPS vehicle identification, computer-aided mapping, radio data transmission, can be helpful. However, at all times, medical dispatching remains a complex human decision-taking process.

From an organizational perspective, we can recognize a one-level rescue system, and a two-tiered and three-tiered system.

The one-level system comprises mainly basic first aid skills and makes medical dispatching almost unnecessary. However, the competences considered as basic first aid skills differ significantly from one country to another. The duration of training varies enormously. Those who advocate the ‘scope and run’ concept are in favour of this system; however, a tiered system has proven to be more effective and efficient [4, 5].

In the tiered systems, different levels of ALS exist. A small proportion of calls require pre-hospital advanced care interventions, including advanced airway management, ACLS, or inotropic drug support. These tiered systems can generally be categorized as: physician-led system and pre-hospital specialist-led system (emergency medical technicians (EMT) or paramedics, with or without EMS physician oversight). Some European countries (UK, Finland) are using similar systems to the US. For calls without emergency characteristics, an ambulance with an EMT crew is sent. For life-threatening conditions, a second response with paramedics is dispatched. The training of paramedics ranges from a 2- to 4-year training. The most common tiered system in Europe is a medicalized second or third level. The training of the physician can vary, from different basic specialties to training specific to emergency medicine [6, 7]. An intermediate medicalized, tiered system can exist with nurses, with or without specific pre-hospital training. The variations in the system and training of the pre-hospital care providers result in a great diversity of medicalized or advanced pre-hospital care. Besides the level of training, the variation in the providers’ origin (independent ambulance service, fire fighters, Red Cross, hospital-based, etc.) and their professional or voluntary status make the complexity of pre-hospital care even more colourful. The usefulness of a tiered system has been debated, but there is evidence that extended procedural capacity and decision-making benefit many patient groups [8].

Drug administration in the pre-hospital setting is allowed in many European countries, but only to physicians. Other EMS professionals can deliver pharmacological therapy only on the basis of standing medical orders, approved protocols, or teleconsultation. In addition, wide differences among countries and services exist on the availability of drugs in ambulances, e.g. for ACS patients.

In addition, the vector used to bring medical teams may also differ, from ambulances, light vehicles, helicopters (helicopter emergency medical services, HEMS), fixed-wing aircrafts to marine rescue. The quality of pre-hospital care is not driven by the vector, but rather by the procedural skills required for rescuing, stabilizing, and treating patients, and the decision-making capacities beyond the rigid pre-hospital protocols of the crew [8]. A recent systematic review on the adherence to guidelines and protocols in the pre-hospital and emergency setting, however, revealed that professionals’ adherence to guidelines demonstrated a wide variation [9].

Finally, transporting the patient to the appropriate definite care is gaining importance. The right hospital for the right patient does not mean that there is an available bed but means bringing the patient to the closest hospital where specialized definite care can be provided. Dispatching a patient with an ST-segment elevation ACS to a hospital without PCI facilities proved to result in worsened outcome [10].

The final step in the pre-hospital chain is the hospital. In different countries, comparable with the tiered ambulance services, there exist a tiered system of EDs and hospitals. This tiered system either can be based on regulations with specific infrastructural and human resource requirements or can purely be based on practical implications of available resources. However, a well-organized and staffed ED that has the capacity to deliver uninterrupted emergency care on a 24 hours a day, 7 days a week basis is crucial. This includes full-time (24 hours/7 days) access to specialized care such as trauma surgery, interventional cardiologists, or radiologists.

Thus, the complete set of out-of-hospital and in-hospital emergencies constitutes the wider EMS. As always, the strength of a chain depends on the weakest link. One of the difficulties is to balance investments between the different links in these systems.

At present, no single region-wide EMS model exists for EU member states. In general, the EMS status of a country depends on its specific geographic, political, cultural, linguistic, historical, and medical setting. Of importance is to recognize if the EMS system is part of a community non-profit agency, a governmental service-based agency, a hospital agency, or a private non-hospital-based agency. It is important to identify that an EMS system in a particular country does not always fit the needs in another country.

The majority of European countries have a government-controlled EMS system or a private-based agency. Both governmental and private-based systems have advantages and disadvantages. The implementation of a unique emergency call number (112) implicitly endorses the use of a unique system in each member state, structured to serve the goal of providing timely and adequate medical rescue and treatment to those in need of urgent medical care.

Moreover, the system can be a separate or combined organization of safety and security services (e.g. police, fire brigade, civil protection, etc.). From a purely technical and management level, a combined system is more efficient, but an increased effectiveness has never been proven.

EMS systems are regulated, in a large majority of member states, by a set of laws and regulations and typically contain the topics outlined in Table 7.2 [11]. It is important to highlight that the majority of EU member states envisage minimum standards of care and equipment, as well as a set of minimum qualifications for EMS professionals.

Considering the relatively young history of EMS and the development of EMS systems throughout Europe, it is not surprising that some countries do not yet have comprehensive laws specifically dealing with the establishment, organization, and regulation of EMS. In addition, given the relationship that EMS shares with other emergency services (e.g. police, fire brigade, civil protection, etc.), it might be more appropriate to consider a broader spectrum of legislative acts that involve the delivery of emergency medical care. The adoption and adherence to minimum standards could form the basis for effective harmonization of the quality of emergency care delivered throughout Europe. However, there is still a long way to go toward a uniform European legislation and policy. Today, the limited European regulations about EMS relate to the minimal regulations on ambulance standards and equipment [11, 12].

The legislative framework in the majority of EU member states implies secured funding mechanisms for EMS. However, financing may be very different from country to country, and, in some countries, even from region to region. Emergency care is provided to all persons by EU member states through the direct or indirect purchasing of services, using various financing mechanisms, most commonly by pooling resources from the state budget and other sources (e.g. national health insurance institutions). This reflects the fact that EMS coordination is considered to be a key responsibility of public authorities, in particular, the role of dispatching [11]. All EU member states proclaimed ‘free access to in-hospital emergency care for all’, including uninsured or unidentified persons. In reality, some countries or regions, or even individual hospitals, invoice patients for emergency care (e.g. ambulance services). However, co-payment for emergency care is waived in the event of life-threatening conditions. Co-payment issues are important, as they may induce underuse of the EMS system and the establishment of alternative care systems. On the other hand, if the system is fully covered by health care insurance, the EMS system is often overused for non-urgent medical demands and includes the risk that the availability of an appropriate team for a real emergency is affected. In addition, the exposure of all teams to real emergencies is diluted, and thus sufficient exposure is also an important component to maintain quality of care.

There are three groups that benefit from a specific and adapted teaching programme: the caller, the dispatcher, and the pre-hospital teams.

Out-of-hospital emergencies occur frequently, and laypersons are often the first to respond to these events. Emergency medicine community educational programmes (MCEPs) may enhance layperson preparedness for medical emergencies. The first and difficult task of MCEPs is to educate potential callers to recognize a potential medical emergency. The second task is to teach the caller how to timely and most efficiently alarm the EMS system in stress or crisis situations. Thirdly, teach how to focus on the critical information needed by the EMD to determine an appropriate course of actions. There are different strategies to enhance layperson preparedness for medical emergencies. The two most used teaching approaches are general public messages using standard media (including ‘new’ media Twitter, Facebook, etc.) or the implementation in standard education programmes in primary or secondary schools.

Core competencies and fundamental skills for EMD include: the ability to operate a variety of communications equipment, including radio consoles, telephones, and computer systems; high tolerance when dealing with high workload, coping with work pressure, and handling various stressful situations or challenges; excellent communication skills with people in various emotional states, good knowledge of different (regional) languages. Finally, good judgement skills in order to best match resources to the medical needs, based on the information obtained from the caller and minimal medical knowledge (e.g. to help callers manage emergency situations while they are waiting for help to arrive), are essential. EMS dispatchers may be asked to distinguish between callers with an immediate need for EMS and those who may safely use alternative services.

As indicated earlier, the composition of pre-hospital teams in Europe varies between member states. Moreover, the training required for (para)medical staff to work in EMS is not standardized. Against this background and aiming for the highest quality of emergency medicine care, the following minimal goals for training and education can be set:

In the field of pre-hospital care, the paucity of high-quality evidence based research to support policies and practice is notable. In the early days of EMS, most clinical practices were not tested in the field. Treatments and diagnostic modalities were extrapolated from the hospital setting to the field, despite tremendous differences in environments, or they were adopted based on limited testing in a controlled setting. The pre-hospital professionals can no longer afford this approach. Thus, the main goals of research in the pre-hospital arena are:

Effective and timely incorporation of research-based evidence into pre-hospital emergency care has the potential to improve survival and good quality of life and be cost-effective [13, 14].

Traditional patient-oriented trial designs can be implemented in pre-hospital trial design (e.g. observational and randomized). In an observational trial design, events are monitored and analysed without an attempt to manipulate or alter the outcome. While this design is simple and suitable in the pre-hospital setting, it cannot define cause and effect relationships and should be considered as hypothesis-generating. These studies are important in the cycle of research, as the problem or current status must be defined before proposing changes. Pre-hospital research particularly lends itself to observational studies, since events under study are sporadic, beyond control, and unpredictable. Within observational studies, we can use a cross-sectional design which measures all variables during a narrow time window and provide data on the prevalence of an outcome or other variables within a population, thus painting a picture of the current status of a problem, or a longitudinal design which follows a group of subjects over time and can better determine a cause–effect relationship. In contrast, case control studies identify subjects, based on the presence or absence of the outcome, and look back to see what differences could account for this outcome occurring, whereas cohort studies identify subjects without the outcome and then expose them to a treatment.

In a randomized design, researchers introduce an intervention and then monitor the effect on outcome. In the specific setting of EMS, this design is often hampered by a lack of control over events and variables. Confounders may cloud or boost differences noted after treatment.

Conducting research in the pre-hospital arena faces important imminent design challenges. These are not always fully appreciated by those not regularly working in this environment. In addition, ethical, legal, and practical aspects also limit the establishment of high-quality pre-hospital research [15].

A major challenge in out-of hospital emergency care research conduct is the issue around informed consent. In the context of research involving people who are incapable of giving informed consent, the Declaration of Helsinki states that, if no patient representative is available and the research cannot be delayed, the study may proceed without informed consent, provided that the specific reasons for involving patients with a disorder that renders them unable to give informed consent have been stated in the research protocol and that the study has been approved by a research ethics committee [16]. For all other patients, written consent is required in emergency care research, despite the delays to treatment that this will usually entail. It should be evident that trials involving the EMS system seek to assess the effects of time-critical treatments for life-threatening disorders such as STEMI, stroke, severe haemorrhage, or respiratory distress. As such, consent rituals by themselves may delay the start of a trial treatment such that the treatment effect could be reduced or obscured. Moreover, the vast majority of EMS physicians commit to providing timely, comprehensive care to acutely ill patients, regardless of their eligibility for research participation. In addition, there must be reasonable evidence that the studied therapy has the potential to provide real and direct benefit. Furthermore, these studies must follow the highest ethical standards and undergo rigorous independent reviews to ensure that these standards are met. Before any patient is enrolled, the community must be consulted and made aware that informed consent cannot be obtained for most study participants before the study is started, as required by law. The legal representatives, and in a later stage the surviving patient, need to be informed as soon as possible to still meet the highest possible ethical standards and to provide the patient full rights as a study patient. However, the European Parliament is debating a revision to the Clinical Trials Directive (2001/20/EC), and it is encouraging that emergency research is included, as it was not in the previous directive [17, 18]. However, the current proposition is open to misinterpretation and does not reflect the reality. Although the precise wording may seem futile, it can have large effects on pre-hospital research in Europe over the next decade.

Some, potentially life-saving, treatment modalities in pre-hospital emergency care are established, based on only limited evidence and expert opinions. To establish a control group, using a placebo group will never be ethically accepted, because one could state that the patient is denied treatment that is accepted to be effective. Thus, the solution is to use existing therapy as control group.

The constant re-evaluation of priorities, and the necessity for clinical care to take precedence over research, makes conducting clinical studies difficult. Study protocols that either facilitate or, at most, minimally impact patient care are more likely to be successfully completed in the pre-hospital setting. Studies that involve EMS resource utilization in excess of typical pre-hospital care are more likely to encounter obstacles or fail.

What may be beneficial in an urban system can be of no effect, or even harmful, in a rural EMS system. Extrapolation of study findings from one EMS system to another should be done with critical caution.

An important challenge is to maintain accuracy and consistency in the interpretation of clinical endpoints across geographic areas and over the course of a trial. The selection of appropriate clinical endpoints and standardization of definitions for single and composite clinical endpoints in pre-hospital care trials are essential prerequisites for quality in emergency care outcome research. Conversely, variability in endpoint definitions creates a barrier to the understanding of results across clinical trials or the pooling of results for the detection of rare safety signals. Emergency care research metrics should be measurable and explicitly define the multiple stakeholders involved.

EMS outcome research has been defined in six Ds outcome categories (see Table 7.3) [14, 19]. Besides reduction of mortality, morbidity, and invalidity, human and economic factors are considered. Although this six Ds outcome categories seem simple and logical, some problems remain—the identification of the most appropriate timing for endpoint assessment being one (arrival at the hospital, discharge from ED or hospital, etc.). To improve pre-hospital research, specific guidelines have helped to improve the quality of the research (see Tables 7.3 and 7.4) [19].

Many die of a heart attack or stroke within the first hour, without even reaching the hospital. As many physicians working in a hospital only did not realize these facts, it took some time to convince them of the need to improve the emergency services offered to patients before they reach the hospital and to promote pre-hospital research on what happens at that critical time, even if it is hard to do.

The clinical outcome in patients with STEMI is largely dependent on time to reperfusion [10]. As longer time from symptom onset to reperfusion therapy has been associated with decreased myocardial reperfusion, and thus increased morbidity and mortality, efforts have been made in reducing ischaemic time. Several studies have presented the benefit of pre-hospital ECG in decreasing door-to-balloon time [20, 21]. However, pre-hospital ECGs are still not routinely obtained in all EMS systems. Transmission via wireless technology is becoming pre-hospital practice and should serve to decrease time to arrival in the angioplasty suite, ultimately decreasing time to reperfusion therapy. In addition, early administration of specific medication has also been demonstrated to be beneficial to patients with STEMI. Depending on the time intervals of transportation, pre-hospital administration of these drugs can make a large difference [10].

This was, and still is, a well-known adagio in trauma care, namely that a severely injured victim is transported preferably to a level 1 trauma centre. But considering the need of early reperfusion strategies for patients with ACS, not only should these patients be transported to a hospital with PCI facilities, but also to one with 24/24 availability of personnel to perform this intervention.

Collaboration in clinical research requires partnership/involvement of a group of clinicians/scientists in the development, implementation, evaluation, and academic aspects, including publication, of a research project. Critical to the research process is an in-depth knowledge of both the clinical condition being studied and the research question. Likewise, planning a clinical study requires an in-depth understanding of care for the involved patients at all stages of the emergency care chain.

The involvement of emergency medicine physicians (EPs) working in the pre-hospital setting in cardiology studies may create a win-win situation. Both cardiologists and EPs gain a better understanding of the challenges and opportunities at their respective stages of care. On the one hand, most cardiologists are not aware of these challenges and opportunities. On the other hand, EMS staff may gain more current knowledge regarding advances in caring for patients with the condition being studied. In addition, EMS staff can be critical in patient recruitment and early treatment. The impact of study operations (e.g. obtaining consent, early pre-hospital blood sampling or other tests, managing complications) is best assessed by EMS personnel. Ideally, the EP should be listed as a co-investigator and be involved with the pre-hospital and ED planning and design phase of the study. Authorship credit should follow, according to the standard authorship requirements. This collaborative models for conducting pre-hospital research was exemplified in the recent STREAM study [10]. Such arrangements may well assist EPs in enhancing academic productivity and improving links between different research groups within an institution and beyond [22].

Rapid growth in information technology and telecommunications has enabled technologies to support advanced services for telemedicine [23, 24]. Emergency telemedicine encompasses the use of telecommunication and information technologies in order to provide timely, specialized emergency care at a distance. It helps to eliminate distance barriers (e.g. distal rural communities) and facilitates collaborative real-time patient management. It allows prompt access and real-time interaction with remote, specialized health care providers. These technologies can be used for early diagnosis and therapy.

In the diagnostic stage, more electronic devices are implanted in patients or ‘at home’ point of care will be used. Video examination of stroke patients in ambulances for earlier stroke recognition has been reported. In advanced telemedicine systems, this diagnostic information can be transferred to the dispatching team as additional information or an alarm. In addition, positioning systems can indicate the exact location of the patient and pre-hospital team. These opportunities can provide even more timely treatment for acutely ill patients. On the other hand, comparable with anti-theft alarm systems, many false positive alarms may be created, resulting in inappropriate EMS use.

In the therapeutic stage, long-distance expert advice, decision-taking, or prescription can change the EMS organization dramatically. The medical involvement, as mentioned previously, varies between different systems but is mainly focusing on triage in the dispatching and medical teams in the field. Medical involvement will significantly increase with these telemedicine systems and will create new diagnostic and therapeutic opportunities. In addition, such emergency telemedicine may contribute to an overall improvement in EMS system efficiency and effectiveness. It may be used in patient triage to avoid unnecessary transfers and ensure necessary transfers in a timely fashion to the most appropriate facility (e.g. remote stroke, STEMI diagnosis).