Emergency medical technician

The Star of Life, a global symbol of emergency medical service

EMTs loading an injured skier into an ambulance

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 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.

EMTs perform medical procedures and respond to emergency calls. The procedures that EMTs may perform differ by country and by US state and are set by their system's medical director in accordance with local laws. Once thought of as only an "ambulance driver" or "attendant," most EMTs now consider usage of these terms derogatory.

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 rapidly (e.g. treatments for cardiac arrest). The EMT's immediate focus is 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 and preserve life while taking the patient to a hospital emergency department for further medical care.

EMTs in the United States of America

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]

Levels of EMTs

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

The NHTSA 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.

EMT-B

EMTs tend to a spiral fracture at a roller derby bout.

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). Splinting a femur fracture may involve use of a traction splint, which will reduce the fracture. 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. Training requirements and treatment protocols vary from area to area.^[7][8]

Intermediate Levels of EMT

EMT-Intermediates are the levels of training between basic (EMT-B) and paramedic (EMT-P). There are 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]).

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.

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]

EMT-P

EMT-Paramedics, who are commonly referred to as simply "paramedics," represents the highest level of EMT, and in general, the highest level of prehospital medical provider, though some areas utilize physicians as providers on air ambulances or as a ground provider^[13]) 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]

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).

Education & training

EMT training programs for certification vary greatly from course to course, provided that each course at least meets local and national requirements. 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.

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]

Employment of EMTs

EMTs are employed in varied settings^[1] ranging from industrial and entertainment first aid positions^[26] to the hospital and health care settings, and to the prehospital environment. The prehospital environment is 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 care.

In places such as Southern California, the primary employer of EMTs (both EMT-Ps and EMT-Bs) is 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. College and university campuses may provide emergency medical responses on their own campus using students.^[29]

In the United Kingdom

The UK has no legal definition of an emergency medical technician, more frequently called an ambulance technician. 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 a move away from the IHCD award, as ambulance services move to employing only university-qualified paramedics and the lower qualified Emergency Care Assistants [ECAs] (based on first aid at work along with emergency driving and basic ambulance skills) or Emergency Care Support Workers [ECSWs] who will have the same skills as ECAs but with some additional skills. IHCD will cease to exist late in 2008, and NHS ambulance trusts are considering how to maintain appropriate skills levels.^[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. 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.

Paramedics in Canada

In Canada the scope of practice of Paramedics is described by the National Occupational Competency Profile (NOCP) for Paramedics document developed by the Paramedic Association of Canada^[34] . Most providers that work in ambulances will be identified as 'Paramedics'. However, in many cases, the most prevalent level of emergency prehospital care is that which is provided by the Emergency Medical Responder (EMR). This is a level of practice recognized under the National Occupational Competency Profile, although unlike the next 3 successive levels of practice, the EMR is not specifically considered a Paramedic, per se. The high number of EMRs across Canada cannot be ignored as contributing a critical role in the chain of survival, although it is a level of practice that is least comprehensive (clinically speaking), and is also generally not consistent with any medical acts beyond advanced first-aid, with the exception of automated external defibrillation (which is still considered a regulated medical act in most provinices in Canada).

Of considerable relevance to understanding the nature of Canadian Paramedic practice, the reader must appreciate the considerable degree of inter-provincial variation. Although a national consensus (by way of the National Occupational Competency Profile) identifies certain knowledge, skills, and abilities as being most synonymous with a given level of Paramedic practice, each province retains ultimate authority in legislating the actual administration and delivery of emergency medical services within its own borders. For this reason, any discussion of Paramedic Practice in Canada is necessarily broad, and general. Specific regulatory frameworks and questions related to Paramedic practice can only definitively be answered by consulting relevant provincial legislation, although provincial Paramedic Associations may often offer a simpler overview of this topic when it is restricted to a province-by-province basis.

Regulatory frameworks vary from province to province, and include direct government regulation (such as Ontario's method of credentialing its practitioners with the title of A-EMCA, or Advanced Emergency Medical Care Assistant) to professional self-regulating bodies, such as the Alberta College of Paramedics. Though the title of Paramedic is a generic description of a category of practitioners, provincial variability in regulatory methods accounts for ongoing differences in actual titles that are ascribed to different levels of practitioners. For example, the province of Alberta uses the title "Emergency Medical Technician", or 'EMT' for the Primary Care Paramedic and 'Paramedic' only for those qualified as Advanced Care Paramedics Advanced Life Support (ALS) providers - but almost all provinces are gradually moving to adopting the new titles, or have at least recognized the NOCP document as a benchmarking document to permit inter-provincial labour mobility of practitioners, regardless of how titles are specifically regulated within their own provincial systems. In this manner, the confusing myriad of titles and occupational descriptions can at least be discussed using a common language for comparison sake.

Primary Care Paramedics

Primary Care Paramedics (PCP) are the entry-level of paramedic practice in Canadian provinces. The scope of practice includes performing semi-automated external defibrillation, interpretation of 4-lead or 12 lead ECG's depending on the area, administration of Symptom Relief Medications for a variety of emergency medical conditions (these include oxygen, epinephrine, glucagon, salbutamol, ASA and nitroglycerine, performing trauma immobilization (including cervical immobilization), and other fundamental basic medical care. Primary Care Paramedics may also receive additional training in order to perform certain skills that are normally in the scope of practice of Advanced Care Paramedics. This is regulated both provincially (by statute) and locally (by the medical director), and ordinarily entails an aspect of medical oversight by a specific body or group of physicians. This is often referred to as Medical Control, or a role played by a base hospital. For example, in the province of Ontario many paramedic services allow Primary Care Paramedics to perform 12-lead ECG interpretation, or initiate intravenous therapy to deliver a few additional medications, such as 50% Dextrose.

Training

Paramedic training in Canada is intense, as paramedics are seen as health professionals, equal in importance to nurses, respiratory therapists, cardiac perfusionists and others. Nevertheless, the nature of training and how it is regulated, like actual paramedic practice, varies from province to province. Training varies regionally, for example, the Primary Care Paramedic training may be three months (British Columbia) to three years (Quebec) in length.

References and Notes

See also

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

External links

• National Highway Traffic Safety Agency, Office of Emergency Medical Services
• National Registry of Emergency Medical Technicians
• National EMS Memorial Service
• National Occupation Competency Profile for Paramedics (Canada)