Emergency medical technician

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The Emergency Medical Technician (EMT) exists in many countries and is a health care provider trained to provide prehospital emergency medical care.^[1] EMTs are divided into numerous levels depending on location and are trained to assist higher level EMTs, paramedics, and other medical personnel (e.g. physicians and nurses). EMTs provide patient care in accordance with protocols and guidelines established by physician medical directors.

Once thought of as only an "ambulance driver" or "attendant," modern EMTs perform a wide variety of medical procedures and responds to many types of emergency calls. The procedures that EMTs may perform at his or her certification level differ by country and by US state and are set by their system's medical director in accordance with local laws.

Types of emergencies that an EMT may be called on to respond to are medical emergencies, hazardous materials exposure, childbirth, child abuse, fires, rescues, trauma and psychiatric crises. EMTs are employed as a part of numerous teams or systems such as by ambulance companies, as a member of technical rescue teams, in career or volunteer fire department, and tactical response teams (e.g. SWAT teams) to name a few.

EMTs are trained in emergency medical procedures that need to be deployed within a rapid time frame from onset of a patient's condition (e.g. treatments for cardiac arrest). The EMT's immediate focus is rapid evaluation of a patient's condition and maintaining a patient's airway, breathing and circulation. Immediate EMT interventions include providing CPR and cardiac defibrillation when necessary, controlling severe external bleeding, preventing shock, immobilization of the neck to prevent further spinal damage, immediate treatment (such as splinting) of bone fractures (both open and closed). Interventions are designed to prevent further injury or disability and preserve life or conditions conducive to life while EMT's expedite transport of the patient to a hospital emergency department for definitive medical care.

[edit] EMTs in the United States of America

[edit] Certification

In the United States, EMTs are certified according to their level of training. Individual states set their own standards of certification (or licensure, in some cases) and all EMT training must meet the minimum requirements as set by the National Highway Traffic Safety Administration's (NHTSA) standards for curriculum.^[2] The National Registry of Emergency Medical Technicians (NREMT) is a private organization^[3] which provides certification exams written based on NHTSA education guidelines.^[4] Currently, NREMT exams are used by 46 states as the sole basis for certification at one or more EMT certification levels.^[5]

[edit] Levels of EMTs

See also: Emergency medical responder levels by U.S. state

The NHTSA currently recognizes four levels of EMTs^[2]:

• EMT-B (Basic)
• EMT-I/85 (Intermediate)
• EMT-I/99 (Intermediate)
• EMT-P (Paramedic)

Some states also recognize the Advanced Practice or Critical Care Paramedic level as a state-specific licensure above that of the Paramedic. In addition, Paramedics can seek out specialty certifications such as Wilderness Paramedic, or Flight Paramedic.

[edit] EMT-B

EMT-Basic is the entry level of EMS.^[6] The procedures and skills allowed at this level are generally non-invasive such as bleeding control, positive pressure ventilation with a bag valve mask, supplemental oxygen administration, and splinting (including full spinal immobilization). Some medications (for example, epinephrine for anaphylactic shock (severe allergic reaction) administered through an autoinjection device such as an EpiPen) can only be administered or "assisted" to a patient with a prior prescription. Treatment options and training requirements vary in restrictiveness and liberalness from area to area though.^[7][8]

[edit] Intermediate Levels of EMT

EMT-Intermediates are the levels of training between basic (EMT-B) and paramedic (EMT-P). There are currently two intermediate levels that are tested for by the NREMT, the EMT-I/85 and the EMT-I/99, with the 1999 level being the more advanced of the two. The standard curriculum for EMT-I from 1998 is defined by the NHTSA, but each state may not have implemented or approved this program. Many states have stopped issuing new Intermediate licensure, instead focusing on maintaining the current lists of intermediates they have, and encouraging the Basic to Paramedic program philosophy. ^[9] Outside of the NHTSA framework, some states have instituted their own intermediate EMT levels using a variety of names (e.g. EMT-II (2) in California^[10] or the levels of Advanced EMT-Intermediate and Advanced EMT-Critical Care in New York^[11]).

[edit] EMT-I/85

EMT-I/85 is a level of training that will typically allow several more invasive procedures than are allowed at the basic level, including IV therapy, the use of multi-lumen airway devices (even endotracheal intubation in some states), and provides for enhanced assessment skills.

[edit] EMT-I/99

The EMT-I/99 represents a higher level than the EMT-I/85 with an expanded scope of practice, such as cardiac monitoring and the administration of additional pharmaceutical interventions, as well as additional training time.^[12]

[edit] EMT-P

EMT-Paramedics, who are commonly referred to as simply "paramedics," represents the highest level of EMT, and in general (some areas utilize physicians as providers on air ambulances or as a ground provider^[13]), the highest level of prehospital medical provider. Paramedics perform a variety of medical procedures such as fluid resuscitation, pharmaceutical administration, obtaining IV access, cardiac monitoring (continuous and 12-lead), and other advanced procedures and assessments.^[14]

[edit] Staffing Levels

An ambulance with only EMT-Bs is considered a basic life support (BLS) unit, an ambulance utilizing EMT-Is is dubbed an intermediate life support (ILS) unit, and an ambulance with paramedics is dubbed an advanced life support (ALS) unit. Some states allow ambulance crews to contain a mix of crews levels (i.e. a basic and a paramedic or an intermediate and a paramedic) to staff ambulances and operate at the level of the highest trained provider. This arrangement is commonly referred to as a Mobile Intensive Care Unit (MICU). There is nothing stopping supplemental crew members to be of a certain certification, though (e.g. if an ALS ambulance is required to have two paramedics, then it is acceptable to have two paramedics and a basic).

[edit] Education & training

EMT training programs for certification vary greatly from course to course, provided that each course at least meets local and national requirments. In the United States, EMT-Bs receive at least 110 hours of classroom training, often reaching or exceeding 120 hours. EMT-Is generally have 200-400 hours of training, and EMT-Ps are trained for 1,000 hours or more. In addition, a minimum number of continuing education (CE) hours are required to maintain certification. For example, to maintain NREMT certification, EMT-Bs must obtain at least 48 hours of additional education and either complete a 24 hour refresher course or complete an additional 24 hours of CEs that would cover, on an hour by hour basis, the same topics as the refresher course would.^[15] Recertification for other levels follows a similar pattern.

EMT training programs vary greatly in calendar length (number of days or months). For example, fast track programs are available for EMT-Bs that are completed in two weeks by holding class for 8 to 12 hours a day for at least two weeks. Other training programs are months long, or up to 2 years for paramedics in an associates degree program. In addition to each level's didactic education, clinical rotations may also be required (especially for levels above EMT-Basic). Similar in a sense to medical school clinical rotations, EMT students are required to spend a required amount of time in an ambulance and on a variety of hospital services (e.g. obstetrics, emergency medicine, surgery, psychiatry) in order to complete a course and become eligible for the certification exam. The number of clinical hours for both time in an ambulance and time in the hour vary depending on local requirements, the level the student is obtaining, and the amount of time it takes the student to show competency.^{[2][16][17][18]} EMT training programs take place at numerous locations, such as universities, community colleges, technical schools, hospitals or EMS academies. Every state in the United States has an EMS lead agency or state office of emergency medical services that regulates and accredits EMT training programs. Most of these offices have web sites to provide information to the public and individuals who are interested in becoming an EMT.

[edit] Medical Direction

In the United States, an EMT's actions in the field are governed by state regulations, local regulations, and by the policies of their EMS organization. The development of these policies are guided by a physician medical director, often with the advice of a medical advisory committee.^[19]

In California, for example, each county's Local Emergency Medical Service Agency (LEMSA) issues a list of standard operating procedures or protocols, under the supervision of the California Emergency Medical Services Authority. These procedures often vary from county to county based on local needs, levels of training and clinical experiences.^[20] New York State has similar procedures, whereas a regional medical-advisory council ("REMAC") determines protocols for one or more counties in a geographical section of the state.^[21]

Treatments and procedures administered by paramedics fall under one of two categories, off-line medical orders (standing orders) or on-line medical orders. On-line medical orders refers to procedures that must be explicitly approved by a base hospital physician or registered nurse through voice communication (generally by phone or radio) and are generally rare or high risk procedures (e.g. rapid sequence induction or cricothyrotomy).^[22] In addition, when multiple levels can perform the same procedure (e.g. AEMT-Critical Care and EMT-Paramedics in New York), a procedure can be both an on-line and a standing order depending on the level of the provider.^[23] Since no set of protocols can cover every patient situation, many systems work with protocols as guidelines and not "cook book" treatment plans.^[24] Finally, systems also have policies in place to handle medical direction when communication failures happen or in disaster situations.^[25]

[edit] Employment of EMTs

EMTs are employed in varied and multiple settings.^[1] These settings range from industrial and entertainment first aid positions^[26] to the hospital and health care settings and finally to the prehospital environment. The prehospital environment is further loosely divided into non-emergency (e.g. hospital discharges) and emergency (9-1-1 calls) services, but many ambulance services operate both non-emergent and emergent ambulance services.

EMTs working in the prehospital emergency environment see a numerous different employment and deployment styles depending on their regional area. In places such as Southern California, the primary employer of EMTs (both EMT-Ps and EMT-Bs) is with the fire department with the fire department providing the primary emergency medical system response^[27]. In other locations, such as Boston, Massachusetts, emergency medical services are provided by a separate, or “third-party,” government agency.^[28] In still other locations, emergency medical services are provided by volunteer agencies. Finally, numerous college and university campuses provide emergency medical responses on their own campus utilizing students.^[29]

[edit] In the United Kingdom

The UK has no legal definition of an emergency medical technician, more frequently called an ambulance technician by those serving in the UK, and as such, there is no legal requirement to have any particular qualification, or indeed, any qualification at all. This is in contrast to the higher paramedic level, which is protected in law, and the inappropriate usage of which title can be prosecuted.

The most widely recognised qualification for a technician is the Institute of Healthcare Development (IHCD, a division of the Edexcel examination board^[30]) ambulance technician qualification, which has been used by every NHS ambulance service. It has also been offered by a number of universities as part of a pre-hospital care course.^[31]

This qualification generally takes around three months to complete, including three weeks of driver training. It is split into five modules, of which two are driving-related and three focus on clinical care.^[32] The higher paramedic qualification involves three additional modules.

There is currently a move away from the IHCD award, as ambulance services move to employing only university-qualified paramedics and the lower qualified emergency care assistants (based on first aid at work along with emergency driving and basic ambulance skills).^[32]

There are many private companies also offering courses titled as emergency medical technician or ambulance technician, with lengths ranging from a five days^[33] to several weeks or other courses such as the Royal College of Surgeons of Edinburgh accredited Pre-Hospital Care Course run by BASICS awarding the Pre-Hospital Emergency Care Certificate. These courses are not recognised by the statutory ambulance services, and any person moving from a private company to the NHS would be required to take an IHCD qualification.

These private service technicians are most likely to work on patient transport work, or as medical cover for public or private events. In some instances, they may provide contracted work to the statutory ambulance service, usually as second-line support units, although they may in some circumstances, respond to 999 emergency calls.

[edit] References and Notes

[edit] See also

• Combat medic
• Emergency medical services
• Emergency Medical Services in the United States
• Emergency medical services in the United Kingdom

[edit] External links

• National Highway Traffic Safety Agency, Office of Emergency Medical Services
• National Registry of Emergency Medical Technicians
• National EMS Memorial Service

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