Osborne and Gaebler's Reinventing Government has sparked discussion amongst elected officials, civil servants, the media, and the general public regarding advantages of privatizing government services. Its support stems from an effort to provide services to municipalities while reducing taxpayer expenditure. Many echo the sentiment of former New York Governor Mario Cuomo, who said, “It is not government's obligation to provide services, but to see that they're provided.” Even in the area of public safety, privatization has found a “market.”

In many localities, privatizing Emergency Medical Services (EMS) is a popular and successful method for providing ambulance services. Privately owned ambulance services staff and respond to medical emergencies in a given community as part of the 9–1–1 emergency response system. Regulations for acceptable response times, equipment, and other essential components of EMS systems are specified by contract. This allows the municipality oversight of the service provided, but it does not provide the service directly. As will be discussed, this “contracting-out” model has many benefits.

Privatizing EMS services is a decision based not only on cost-savings, but on accountability. A thorough evaluation must be utilized in the selection process. Issues of efficiency, effectiveness, quality, customer service, responsiveness, and equity must be considered by the government, in addition to cost of service.

The uncertain future of health care in the United States has led those in EMS to look beyond the field's internal market to explore additional opportunities for expanding and redefining its roles beyond emergency care. It is important, however, to consider how emergency medical care, the original role of EMS, can be best delivered. Responding to emergencies is not just one of the functions involved in this field, it is the principal function from which public perception of EMS is formed, and from which support for entering other markets can be fostered.

The purpose of this paper is to present several important concepts and considerations that public officials, medical directors, and the public must be aware of when contemplating the possibility of privatizing their Emergency Medical Services. A review of the general concepts of privatization and issues of accountability will be presented, referencing policy experts, followed by an examination of how advocates of privatization might see these issues as they relate to providing EMS. The conclusion will present prescriptions for both municipal and commercial ambulance providers.

Until now, the public health response to the threat of an epidemic has involved coordination of efforts between federal agencies, local health departments, and individual hospitals, with no defined role for prehospital emergency medical services (EMS) providers.

Representatives from the local health department, hospital consortium, and prehospital EMS providers developed an interim plan for dealing with an epidemic alert. The plan allowed for the prehospital use of appropriate isolation procedures, prophylaxis of personnel, and predesignation of receiving hospitals for patients suspected of having infection. Additionally, a dual notification system utilizing an EMS physician and a representative from the Office of Infectious Diseases from the hospital group was implemented to ensure that all potential cases were captured. Initially, the plan was employed only for those cases arising from the Centers for Disease Control and Prevention (CDCJ/Public Health Service (PHS) quarantine unit at the airport, but its use later was expanded to include all potential cases within the 9–1–1 system.

In the two test situations in which it was employed, the plan incorporating the prehospital EMS sector worked well and extended the “surveillance net” further into the community. During the Pneumonic Plague alert, EMS responded to the quarantine facilities at the airport five times and transported two patients to isolation facilities. Two additional patients were identified and transported to isolation facilities from calls within the 9–1–1 system. In all four isolated cases, Pneumonic Plague was ruled out. During the Ebola alert, no potential cases were identified.

The incorporation of the prehospital sector into an already existing framework for public health emergencies (i.e., epidemics), enhances the reach of the public safety surveillance net and ensure that proper isolation is continued from identification of a possible case to arrival at a definitive treatment facility.

A multiple patient incident involving a commercial airliner is a challenge for any community EMS system. When the community is on a remote island in the North Pacific Ocean, where there is no hospital and only a small clinic staffed by just one physician and several nurses and technicians, the challenge is much greater. The incident described herein necessitated providing emergency care at the airport, and at the same time, activating a response capability from hundreds of miles away to transport the patients to definitive care. The situation was compounded further by the fact that most of those injured spoke little or no English. This paper reviews the events that occurred and the lessons learned..

To identify the events that occurred when a commercial airliner, with more than 250 passengers and crew aboard, experienced an in-flight “upset” that resulted in many being injured. What was learned may help other areas be better prepared for such events.

A commercial airliner incident that occurred in April, 1993 resulted in the need for emergency medical care at the remote island location of Shemya, Alaska initially, and fixed-wing transport of the injured to definitive care in Anchorage, Alaska, USA, which is about 1,300 miles (2,130 km) from Shemya.

A case review methodology was used that included interviews with key persons involved in the response to this incident to learn first-hand what occurred; by review of the National Transportation Safety Board (NTSB) reports, and by having agencies involved in the event review draft report materials to ensure accuracy.

This study showed how a remote site with a small cadre of medically trained personnel could organize and effectively provide initial emergency care for >200 persons, an have them transported more than a thousand miles to definitive care.

Valuable lessons were learned from this incident that may help other areas be better prepared, particularly in remote areas, for large multiple patient events.

There has been relatively little attention paid to the mid- and long-term effects of large-scale disasters, particularly their effects on children and young people. At the present time, the impact of the Chernobyl catastrophe on the daily lives of the affected population may include one of strong psychological stress due to uncertainty about ultimate health outcomes. Persons in the Chernobyl region in specific areas of low contamination may be affected similarly. This investigation assesses radiation concerns and attitudes about health and government information, nine years after the disaster, in a group of adults and adolescents residing in a relatively uncontaminated village in the Chernobyl area.

Questionnaires were administered to 94 adults and 50 adolescents. Items assessed beliefs about extent of radiation exposure, health concerns regarding oneself and family members, past and current pre-occupation about the disaster, and trust in the accuracy of government information about health effects.

Considerable uncertainty was demonstrated in both adults and adolescents about the extent of their and their families exposure to radiation. Marked distrust of past and current government information about health effects was evident. A large proportion of subjects reported that they still thought frequently about the Chernobyl accident. They worried about health problems related to radiation exposure whenever they or their family members exhibited physical symptoms or complaints, and they urged family members to go to a medical clinic for evaluation to assess these symptoms.

The extent of long-term concerns about the personal and family health effects of the Chernobyl disaster in this population residing in a relatively uncontaminated village is striking: the psychological impact on adolescents is considerable. The stress generated is maintained by the realistic uncertainty about the ultimate health consequences to the overall population as a result of radiation exposure and distrust in government information about contamination levels in this particular village. The level of stress and its effects on physical and mental health may increase over time if there is a rise in morbidity in the area. The continuing health needs of the extremely large population affected by the Chernobyl disaster need to be addressed.

More than 2 million refugees, 2–3 million displaced persons internally, thousands of unaccompanied children, and a total number of reported fatalities of 48,347 in Goma, Zaire.

International relief support started with coordination provided by the United Nations High Commissioner for Refugees (UNHCR). In the first phase, availability of potable water was the highest priority. Current priorities are to intensify repatriation of Rwandan refugees under conditions that will guarantee human rights and allow for dignified daily living.

Education beginning at childhood, to overcome conflicts, social inequality, and overpopulation should be promoted by assisting governments, instead of pursuing policies aimed largely at forwarding their own national interests.

Hand held, colorimetric, end-tidal CO2 detector devices are being used to verify correct endotracheal tube (ETT) placement. The accuracy of these devices has been questioned in situations of cardiac arrest. The use of the esophageal detector device (EDD) is an easy alternative for detection of ETT placement, and may be more accurate in situations of cardiac arrest.

The use of the esophageal aspiration device in comparison with a colorimetric end-tidal CO2 detector is more accurate in detecting proper ETT placement and easier to use in the prehospital setting than is the colorimetric end-tidal CO2 detection device.

This was a prospective alternating weeks, 6-month study in a prehospital setting. Participants included all patients older than 18 years who were intubated by the Portsmouth, Virginia Emergency Medical Services (EMS) personnel from 01 July 1993 through 31 December 1993. The aspiration device used, also known as an esophageal detector device (EDD), was a 60 ml, luer-lock syringe attached to a 15 mm ETT adapter. Its efficacy was compared with an already accepted method of ETT position detection, the colorimetric endtidal CO2 detector. Each device was used on alternating weeks, and correct ETT placement was determined by the receiving emergency department physician using standard techniques. Chi-square analysis and Fisher's Exact test were used to compare parameters, time of device use, and ease of use. Sensitivity and specificity were calculated, and provider preference was assessed using a survey instrument administered following completion of the study.

There were 49 patients who met the inclusion criteria, but six were excluded because of situational circumstances rendering use of the device a possible compromise of patient care. Twenty-five patients were in the EDD group, and 18 were in the endtidal CO2 detector group. There was no statistically significant difference detected between groups for the gender ratio, underlying condition, CPR in progress, perceived difficulty of intubation, or percentage of nasotracheal intubation. The EDD was significantly easier to use (p<0.005). There was no statistically significant difference in time required for use of end-tidal CO2 detector device versus the EDD. The sensitivity and specificity for correct tracheal placement using the EDD was 100%, and the sensitivity for correct tracheal placement using the end-tidal CO2 detector device was 78%. Use of the EDD was preferred over use of the end-tidal CO2 detector device by 75% of participating EMS providers. One case of nasotracheal intubation with an ETT placement above the cords raised the question of accuracy of this device in situations where direct visualization is not utilized.

The EDD was accurate in all cases of orotracheal intubation, and was easier to use than was end-tidal CO2 detector device. It was preferred by 75% of participating EMS providers. In cases in which the ETT may be above the vocal cords, caution must be used with interpreting the results obtained by use of the EDD.

Devices used for support of patients requiring air rescue or conveyance are subjected to severe environments that may affect their ability to function when needed or may affect other systems within the transporting vehicle.

The ability of four portable ventilators, a suction device, and plastic and rubber tracheal tubes to withstand changes in temperature, vibration, sudden deceleration, and electromagnetic fields was studied in the laboratory setting. In addition, the effects of the operation of these devices on the flight instrumentation was investigated.

All of the ventilators tested delivered stable minute volumes at temperatures above zero, but in sub-zero temperatures problems were encountered with the driving gas. Vibrations produced alterations in the performance of two of the ventilators, and resonant frequencies were detected that are identical to those produced by the rotors of the helicopter used.

Suctioning became difficult at temperatures below −5° C as the mucus froze in the collecting tubing. The motor produced electromagnetic fields that interfered with the aircraft instrumentation, and resonant frequencies had a deleterious effect on the circuit boards. Plastic tubes were adversely affected by cold, and these chilled tubes were excessively sensitive to vibration and shocks.

The devices used in various aircraft influence certain vital maneuver systems of the craft. Studies on portable ventilators, a suction device, and tracheal tubes showed that, under specific conditions, the equipment was safe to patients and was not hazardous to the aviation safety. However, under certain conditions commonly encountered during air rescue operations, the equipment became dys-functional or presented safety hazards to the aircraft, and, hence, the crew. The Swedish Air Force has adopted three different criteria constellations: 1) operative; 2) storing; and 3) transport environment.