An
Emergency Medical Technician (
EMT) is an emergency responder trained to provide
emergency medical services to the critically ill and injured. In an
advanced life support (ALS) service the EMT plays a largely supportive role assisting a
paramedic like a
nurse assists a
doctor in the
hospital. In
basic life support (BLS) services EMT's are solely responsible for the care and emergency treatment of their patients.
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 standards state that rescuers be medically certified, many EMT's are also part of Technical Rescue teams, such as Extrication, Rope Rescue, and Water Rescue. They may be part of an Emergency Medical Service (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.
Certification The
National Registry of Emergency Medical Technicians (NREMT) is a private organization
National Registry 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)
Levels of EMTs An
Emergency Medical Technician - 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 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, endotrachael intubation, nasogastric tubes, use of
cardiac event monitors/
ECGs, and medication administration to control certain cardiac Arrhythmias.
EMT-I/99 In addition to the DOT (Department of Transportation) established standards, some states issue licenses for more specialized levels of training. Other states simply use different names for the above.
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).
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.
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).
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.
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 realize reciprocity with other states.
The first-level ALS provider in the State of Rhode Island is the EMT-Cardiac, which is unique to Rhode Island and Virginia (Virginia has recently phased out the Cardiac Tech program). In Virginia, the first level of ALS is EMT-Enhanced, which is unique to Virginia. EMT-Enhanced can start IV lines, perform endotracheal intubation and administer some medications such as D50, glucagon, albuterol/atrovent and in some cases narcotics. 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.
An ambulance with only EMT-Bs is considered a BLS or
Basic Life Support unit whereas an ambulance with EMT-Ps, 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. 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
[1]). 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.
Higher Levels of EMTs 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 suppliment their training.
Education & training 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.
Medical Direction 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).
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