Emergency medical technician

An Emergency Medical Technician (EMT) is an emergency prehospital care provider in the United States trained to provide emergency medical services to the critically ill and injured. EMTs can be either Advanced Life Support (ALS) providers or Basic Life Support (BLS) providers. In an advanced life support (ALS) service, the EMT-Basic plays a largely supportive role by assisting a paramedic (EMT-P) in providing ALS care. In basic life support (BLS) services EMT-Bs are solely responsible for the care and emergency treatment of their patients in accordance with medical direction. The EMT is similar to an Emergency Medical Attendant in Canada and has counterparts in different countries with differing titles.

Once thought of as an "ambulance driver" or "attendant," the modern EMT performs a wide variety of duties and responds to many types of emergency calls. The duties which the EMT may perform at his or her certification level are dictated by state laws which define the EMT's scope of practice. Types of emergencies that an EMT may be called on to respond to are medical emergencies, hazardous materials exposure, childbirth, child abuse, fires, rescues, injuries, trauma and psychiatric crises. As National Fire Protection Association standards state, rescuers should be medically certified. Many EMTs are also part of Technical Rescue teams, such as Extrication, Rope Rescue, and Water Rescue. They may also be part of an Emergency Medical Service (EMS), career or volunteer Fire department, or independent rescue team.

EMTs are trained in practical emergency medicine and skills that can be deployed within a rapid time frame. Patient treatment guidelines are described in local 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. In addition, EMT intervention aims to provice CPR and defibrillation when necessary, 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.

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). All EMT training must meet the minimum requirements as set forth in the U.S. Department of Transportation's standards for curriculum.

National Registry
The National Registry of Emergency Medical Technicians (NREMT) is a private organization which sets voluntary standards and examines and certifies EMT candidates using its written and practical skills exams. While most states 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 (DOT) recognizes four levels of EMTs:


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

Intermediate Levels of EMTs
An EMT-Intermediate is the level of training between Basic (EMT-B) and Paramedic. There are actually two intermediate levels, the EMT-I/85 and the EMT-I/99 curriculum, with the 1999 level being the higher of the two. The standard curriculum for EMT-I from 1998 is defined by the U.S. Department of Transportation, but each state may not have implemented or approved this program.

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. The EMT-I/85 is typically allowed only the same medications an EMT-B is allowed to use (these being oxygen administration, oral glucose, activated charcoal, epinephrine auto-injectors (Epi-Pens), nitroglycerine, and Metered-Dose Inhalers (MDIs), though in many states administration of 5 and 50% dextrose in water is also allowed (commonly referred to as D5W and D50 respectively)). Protocols for medications vary by state. For example, in New Hampshire, an EMT-I is allowed to administer Narcan, Atropine, Thiamine, and nebulized Albuterol in addition to the above listed medications.

EMT-I/99
The EMT-I/99 level is the closest level of certification to Paramedic, and allows many techniques not available to the EMT-I/85 or below. Some of these techniques include needle-decompression of tension pneumothorax, endotracheal intubation, nasogastric tubes, use of cardiac event monitors/ECGs, and medication administration to control certain cardiac Arrhythmias.

Higher Levels of EMTs
In addition to the United States Department of Transportation established standards, some states issue licenses for more specialized levels of training. Other states simply use different names for the above.

Alaska has an EMT-II, which is very similar to the I/85 standard, and the EMT-III, which is closer to the I/99 standard; interestingly a sponsoring physician can broaden the scope of an EMT-III beyond state-defined protocols by providing additional training and quality control measures. This means that additional drugs and procedures (including wound suturing) can be accomplished by an appropriately trained EMT-III. The EMT-III program is a short upgrade program, and does not generally receive reciprocity with other states.

California uses 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).

Iowa EMT-Basics can administer Epi-pen per protocol, insert a Combi-tub, and can set-up and maintain an IV that is non-medicated as well as all other basic skills. (Not establish an IV.) EMT-Intermediates can establish an IV as well as do all of the EMT-Basic skills. An Iowa Paramedic is a NREMT-Intermediate/99 and is not the highest level of care in Iowa. This allows them to insert ET Tubes, Needle Decompression, Manual Defib., and administer medication. The Iowa Paramedic Specialist is the NREMT-Paramedic. Iowa also has a Critical Care endorsement for Paramedic Specialists.

Michigan recognizes the DOT levels of EMT-B, EMT-I/85, and EMT-P, however they refer to an EMT-I/85 as an EMT-S (Specialist). However, since standards for EMT-Basic are nearing the EMT-Paramedic level, the EMT-Specialist is slowly being phased out.

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. However, no advanced EMT certifications are recognized in New York City. One is either an EMT-B or a Paramedic.

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.

Rhode Island's first-level ALS providers is EMT-Cardiac, which is unique to Rhode Island and Virginia (Virginia has recently phased out the Cardiac Tech program). 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 Rhode Island fire departments, who provide Emergency Medical Services in the majority of the state.

Tennessee EMTs are licensed at either the EMT-IV (Intravenous Therapy) Level or the EMT-Paramedic Level. EMT-IVs are trained to the NREMT-B standard in accordance with DOT regulations, as well as receive additional training in advanced airway management, administration of Epinephrine 1:1000 in Anaphylaxis, administration of nebulized and aerosolized Beta-2 Agonists such as Xopanex and Albuterol, administration of D50W and D25W, IV Therapy and Access, and trauma life support including the use of MAST Trousers. EMT-IVs can also administer nitroglycerine and aspirin in the event of cardiac emergencies, and can give Glucagon. EMT-IVs can also administer the Mark 1 Autoinjector kit for Organophospate poisoning and suspected nerve gas exposure. The State of TN Board of EMS is currently evaluating allowing EMT-IVs to administer NARCAN and Nitrous Oxide, as well.

In Virginia, the first level of ALS is EMT-Enhanced, which is unique to Virginia. EMT-Enhanced can start IV lines, perform endotracheal intubation, perform chest decompressions, establish IO lines and administer some medications such as D50, glucagon, albuterol/atrovent, epinephrine and in some cases narcotics. Virginia has recently phased out its Cardiac Tech program.

Wisconsin offers an EMT-IV-Technician certification for the EMT-Basic, allowing them to start basic IV lines, treat for hypovolemic shock, administer Narcan, D5, and a limited number of other medications. This level of training is often used in non-urban areas where hospitals may be sparse and Advanced Life Support intercepts or aero-medical transports can take a great deal of time. Additionally, some private ambulance companies employ EMT-IV Technicians for interfacility transports which only require IV therapy and do not necessitate the specialized advanced care of a paramedic, EMT-I, RN or MD.

An ambulance with only EMT-Bs is considered a BLS or Basic Life Support unit whereas an ambulance with EMT-Ps or EMT-Is, is dubbed an ALS or Advanced Life Support unit. Some states have combination "P-B" (Paramedic-Basic) crews that staff ambulances and operate at the ALS level, though additional certification is required for an EMT-B to operate at that level.

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. 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 New Hampshire all EMT-Bs as of 2007 are trained in two blind insertion airway devices: the King-LTD, and CombiTube. In addition to blind insertion airways New Hampshire EMT-Bs are trained to perform an advanced spinal assessment which allows them to rule out the necessity of spinal immobilization, apply a 12 lead cardiac monitor for advanced providers, and manage a patient's tracheostomy tube. Wisconsin also trains EMT-Bs in the use of the CombiTube as well as advanced spinal immobilization criteria.

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. In the state of Tennessee, EMT-Bs are referred to as EMT-IV and are trained in the use of IV therapy and the pharyngeo-tracheal lumen ("PTL") or CombiTube advanced airway adjuncts.

Education & training
Like the responsibilities of an EMT, training programs for certification vary greatly. 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. The specifics of education often depend on local rules and laws.



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 in the case of EMT-Bs. The level of motivation and the time constraints of the students should be taken into consideration before enrolling into this type of program. Other training programs are months long, or up to 2 years for paramedics. 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.

The training of EMTs may take place at 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. Many of these offices have Web sites to provide information to the public and individuals who are interested in being trained as EMTs.

Many EMT students and schools used medical and healthcare educational software to supplement their training. Others use online resources to exchange ideas and training such as the site EMT City (www.emtcity.com) or JEMS (www.jems.com).

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 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 performing a surgical cricothyrotomy and inserting an endotracheal tube.

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. This can be treated by sticking a hollow angiocatheter directly into the chest when necessary to save a life

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), Basic Trauma Life Support (BTLS), Advanced Cardiac Life Support (ACLS), Pediatric Education for Prehospital Professionals (PEPP), 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) several of these certifications (according to local protocols) 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).

Paperwork
There is much more to being an EMT than just administering medical treatment and transport. For every call an EMT receives a variety of paperwork must be filled out. Documents must be made noting the patient's past medical history, treatment and drugs administered, recordings of the patient's vital signs and much more. These documents ensure the continuity of patient care from EMS providers to hospital doctors and nurses. The paperwork also ensures that EMTs are practicing good medicine and that the techniques they are using are effective. Another crucial role of documenting 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.

Electronic patient care reporting is the newest form of documentation now being used by many EMS services. Many states now require electronic documentation, as well as HIPAA requirements.