Emergency medical technician
From Wikipedia, the free encyclopedia
An Emergency Medical Technician (EMT) is an emergency responder trained to provide emergency medical services to the critically ill and injured.
Once thought of as an "ambulance driver or attendant," the modern EMT performs many more duties than in the past, and responds to many types of emergency calls, including medical emergencies, hazardous materials exposure, childbirth, child abuse, fires, rescues, injuries, trauma and psychiatric crises. As National Fire Protection Association regulations state that Rescuers be medically certified, many EMT's are also part of Technical Rescue teams, such as Extrication, Rope Rescue, Water Rescue, etc. They may be part of an EMS, Fire, or independent rescue team.
EMTs are trained in practical emergency medical knowledge and skills that can be deployed within a rapid time frame. Patient treatment guidelines are described in protocols following both national guidelines and local medical policies. The goal of EMT intervention is to rapidly evaluate a patient's condition and to maintain a patient's airway, breathing and circulation by CPR and defibrillation. In addition, EMT intervention aims to control external bleeding, prevent shock, and prevent further injury or disability by immobilizing potential spinal or other bone fractures, while expediting the safe and timely transport of the patient to a hospital emergency department for definitive medical care.
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). All EMT training must meet the minimum requirements as set forth in the U.S. Department of Transportation's standards for curriculum.
The National Registry of Emergency Medical Technicians (NREMT) is a private organization and voluntary standards and testing body which examines and certifies EMT candidates using its written and practical skills exams. While most states do accept the credentials of the National Registry as equivalent to, or in place of, their own certification, not all states do. Currently, NREMT exams are used by 46 states as the sole basis for certification at one or more EMT certification levels. 
Levels of EMTs
The US Department of Transportation recognizes four levels of EMTs:
- EMT-B (Basic)
- EMT-I/85 (Intermediate)
- EMT-I/99 (Intermediate)
- EMT-P (Paramedic)
Some states such as California use an EMT-I or "EMT-One" Roman numeral designation which is equivalent to the National EMT-Basic; this should not be confused with the EMT-Intermediate (hereafter EMT-I). New York State has an AEMT-CC (Advanced EMT - Critical Care) certification, which is unique to New York, but almost identical in curriculum to the national standard EMT-Intermediate/99. Part of the reason why New York possesses this level is that it also has an AEMT-I (Advanced EMT- Intermediate) certification which is at the same level as the national standard for EMT-I/85. Oklahoma recognized a similar level, called EMT-Cardiac, until recently; however, that level has been phased out, and EMTs certified in Oklahoma at that level have since been trained and certified to the paramedic level or downgraded to EMT-I.
The first-level ALS provider in the State of Rhode Island is the EMT-Cardiac, which is unique to Rhode Island (and Virginia). The EMT-C is a certification between the EMT-I and EMT-P, allowing the use of more cardiac drugs than the EMT-I, but fewer than the EMT-P. The time and cost of an EMT-C program is generally less than 1/3 that of an EMT-P program, and is much more popular. EMT-C or higher licensure is generally required by fire departments in the state as well, who provide Emergency Medical Services in the majority of the state.
An ambulance with only EMT-Bs is considered a BLS or Basic Life Support unit whereas an ambulance with EMT-Ps, EMT-Is (I/99 Standard), is dubbed an ALS or Advanced Life Support unit. Additionally, an ambulance whose highest provider is an EMT-I (I/85 standard), is considered an ILS or Intermediate Life Support Unit.
Many fire-based companies also provide "rescue" services, such as motor vehicle extrication, all aspects of technical rescue and water rescue. It is part of an EMT duty in most states to be able "extricate a person" from whatever situation the EMT is presented with, whether the person fell down a flight of stairs and is in a cellar, or is stuck in a motor vehicle.
EMT-B skills include CPR, first aid, airway management, oxygen administration, spinal immobilization, bleeding control and traction splinting. EMT-B's can also assist the patient in taking their own prescribed nitroglycerin tablets, β-2 agonist Metered Dose Inhalers, and Epinepherine auto-injectors.  In some regions, protocols may allow an EMT-B to administer these medications to patients for whom they are indicated even if they are not currently prescribed them. EMT-I skills add IV therapy, endotracheal intubation and initial cardiac drug therapy.
Some EMT-Bs are also trained in use of the pharyngeo-tracheal lumen ("PTL") or CombiTube advanced airway adjuncts, and the activation of aeromedical assets. In the states of Ohio, South Carolina, and Nebraska, EMT Bs are trained using a modified NREMT-B curriculum with the addition of endotracheal intubation (in the State of Ohio however, the patient must be apneic and without a pulse for an EMT-B to intubate).
Like the responsibilities of an EMT, training programs for certification vary greatly. On one end of the spectrum, there are fast track programs that can be very intense often demanding a schedule of 8 to 12 hour days for at least two weeks. The level of motivation and time constraints of the students should be taken into consideration before enrolling into this type of program. On the other side of the spectrum are 3 to 4 month training programs whose popular venue is a local community college. Training consists of a few hours a day, couple days a week of classroom time. In addition, field time is also required, where the student must complete specific rotations in the hospital setting, and also gain experience on the ambulance under the guidance of an EMS service's preceptor. The number of hours in the field vary depending on the state's requirements and the amount of time it takes the student to show competency in their skills. In-field training can easily exceed the actual classroom hours. For those seeking EMT as a pre-requisite to become a paramedic or firefighter, longer programs may not be ideal because a 4 month program will add even more time to the typical 2 year paramedic or firefighter program.
Regardless of their level of training, 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 rules is guided by a physician, often with the advice of a medical advisory committee. A physician acting in direct supervision of an EMT program is referred to as a Medical Director and the supervision provided is referred to as Medical Direction.
In California, for example, each county 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. New York State has similar procedures, where a regional medical-advisory council ("REMAC") determines protocols for one or more counties in a geographical section of the state. In other areas of the US, a list of permitted actions ("Acts Allowed" list) may be issued by a state or local authority.
Some skills may be performed "by protocol" given that certain conditions exist, "off-line medical direction," or "standing orders." Other skills require the prior approval of a physician by radio or telephone, or "on-line medical direction." Some areas maintain an "Austere Care Protocol" which modifies the level of care provided during communications failures or disasters.
Paramedics (EMT-Ps) receive more advanced education and training, including instruction on pharmacology and the administration of lifesaving drugs; the technique of inserting a breathing tube into a person's lungs as in intubation; and even surgical techniques such as sticking a hollow needle directly into the trachea (cricothyrotomy) or the chest when necessary to save a life.
For example, if air in the chest (outside of the lungs) called a pneumothorax is preventing the lungs from expanding, the chest must be decompressed to allow the lungs to expand normally and allow inspired air to reach the alveoli so that oxygen can enter the bloodstream.
The use of these invasive skills is governed by complex protocols intended to maximize the life-saving value of bringing these skills to the patient in the field while minimizing the risk of errors or additional injury to patients.
PreHospital Trauma Life Support(PHTLS), Advanced Cardiac Life Support (ACLS), and Pediatric Advanced Life Support(PALS) are other additional certifications available to EMTs to enhance their capabilities. For some higher levels of care, such as Paramedic or EMT-I/99 (AEMT-CCT) these certifications may be required before an EMT is allowed to practice.
Employment of EMTs
EMTs may be employed by a commercial, hospital or municipal EMS (Emergency Medical Service) agency or fire department. Some EMTs may be employed by commercial ambulance services providing non-emergency patient transportation, or providing emergency medical services to 9-1-1 emergency calls under contract with municipalities or county governments. Some EMTs may work in clinical settings, such as a hospital's emergency department, while others may be employed in an industrial setting, or for 'home health care' providers.
EMTs may be employed by private ambulance services, sometimes providing non-emergency transportation of in-hospital patients. Many ambulance services provide transport for patients not experiencing an emergency, but nonetheless requiring medically supervised transportation. Such patients may include those being transferred between hospitals, bedridden patients being discharged to nursing homes or hospices, or patients who are to undergo specialized treatment, therapy or diagnostic procedures. Private ambulance services in some districts and towns are contracted to respond to 911 emergency calls.
In many locales, firefighters and some police officers are now also cross-trained as EMTs; the majority of these are EMT-Bs, although a growing number of prospective firefighters earn EMT-P certification in order to increase their chances of being hired. Some large companies, especially industrial facilities, even maintain their own in-house EMTs as part of the plant's firefighting or security guard force. Some colleges and universities train EMTs and host student run EMS in their areas to respond to student medical emergencies.
EMTs may also serve as an unpaid volunteer for a volunteer ambulance service, volunteer rescue squad or volunteer fire department, especially in rural or suburban areas. Rural communities often find it difficult to finance emergency medical services, and recruiting, training and retaining volunteer EMTs is a continuing challenge. This is especially true in small communities since the EMTs who volunteer often know personally the patients they're dealing with. One of the benefits of having volunteers is that they provide medical services for free, whereas a paid company can charge up to $2,000 per trip to the hospital. Experienced volunteers are also valuable as many suburban and rural fire companies who are taking over rescue are not medically trained. Further, it has been reported that in a time of crisis, there would not be enough paid EMS workers to properly staff a major incident. Many of the immediate EMS personnel that responded to 9/11/01 after the towers collapsed were actually volunteers.
In response to recent nursing shortages, EMT-Ps are being increasingly used in the emergency rooms and Intensive Care Units of hospitals, where they can serve as ER technicians or assistants, with varying scopes of practice.
Prior to the Hurricane Katrina catastrophe, in the United States of America, the busiest EMS service per ambulance was New Orleans' Health Department EMS, which responded to approximately 4,000 9-1-1 calls per month, utilizing six ambulances for an entire city of about 450,000 people.
EMTs and paramedics of the New York City Fire Department's Emergency Medical Service Command, along with hospital employed EMTs and paramedics under its jurisdiction, responds to over 3,000 requests for 9-1-1 assistance daily; over 1.3 million calls annually (2003).
There is much more to being an EMT than just the administering of medical treatment. For every call an EMT receives, a variety of paperwork must be filled out. Documents must be filled out noting the patient's medical history, the treatment and drugs that were administered, the patient's vitals and much more. These documents help to make a smooth transfer of patient care from the EMTs to the hospital where the patient is being taken. The paperwork also helps ensure the EMTs are practicing good medicine and the techniques they are using are effective. Another crucial role of documenting the medical care is allowing the response centers to monitor call flow. With all the information in the system, an accurate account of call volume and history can be taken to designate ambulance stations.
References and Notes
- ^ http://nremt.org/about/Legal_Opinion.asp
- ^ Acceptance of National Registry Certification by State
- ^ EMT-B National Standard Curriculum
- First aid, Wilderness first aid, Wilderness emergency medical technician, Oxygen first aid
- Medical emergency, Emergency medical services
- Paramedic, Medic, Combat medic, 68W
- Certified first responder, Combat lifesaver
- Rescue squad
- National Registry of Emergency Medical Technicians
- National Association of Emergency Medical Technicians
- National Highway Traffic Safety Agency, Office of Emergency Medical Services
- The Difference Between an EMT and a Paramedic