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What is EMS?

Emergency Medical Services, more commonly known as EMS, is a system that provides emergency medical care. It is activated by a call for help, after an incident of serious illness or injury. The focus of EMS is emergency medical care of the patient(s). EMS is most easily recognized when emergency vehicles or helicopters are seen responding to emergency incidents. But EMS is much more than a ride to the hospital. It is a system of coordinated response and emergency medical care, involving multiple people and agencies. A comprehensive EMS system is ready every day for every kind of emergency. www.ems.gov

Overview of the EMS Profession
(excerpts from National Scope of Practice Model 2007, pgs 18-19)

The National EMS Scope of Practice Model defines the practice of EMS personnel. EMS personnel are unique health care professionals in that they provide medical care and transportation in an out-of-hospital setting with medical oversight. EMS personnel are not independent practitioners. While the practice is not independent, it is relatively unsupervised and often has little backup. Therefore, EMS personnel must be able to exercise considerable judgment, problem-solving, and decision-making skills.

Most EMS personnel work in emergency medical organizations that respond to emergency calls. Emergency response is typically a local government function (or contracted by local government to a private entity). In most communities, citizens call 9-1-1 when they need emergency medical care, and the appropriate EMS resources are dispatched. EMS personnel respond and provide care to the patient in the setting in which the patient became ill or injured, including the home, field, work, industrial, and recreational settings. In the case of emergency calls, EMS personnel are unique in that they typically have a “duty to act.”

Many EMS personnel provide medical transportation services for patients requiring medically supervised transportation, either exclusively or in addition to emergency response. These “medical transports” generally do not fall under the “duty to act” responsibility of emergency response. Some EMS personnel provide inter-facility transfers of very high acuity patients.

In some cases, EMS personnel “stand by” at mass gatherings (for example, concerts, sporting events, etc.) and high-risk activities (for example, fireground operations, etc.). EMS personnel occasionally serve a combined emergency response and occupational/primary care role in remote areas (for example, off-shore oil rigs, wildland fires, etc.) Increasing numbers of EMS personnel are working in more traditional health care settings in the hospital (especially emergency departments), urgent care centers, doctor’s offices and long-term care facilities. Finally, EMS personnel are becoming involved in numerous public health initiatives (immunizations, illness and injury prevention programs, etc.).

Emergency Medical Services are a local function and organized in a variety of ways. Common models are municipal government (fire-based or third-service) or a contracted service with a private (profit or nonprofit) entity. EMS personnel also can be categorized in a variety of ways. Those trained to higher levels tend to be paid (either full or part time) while those trained to lower levels tend to be volunteers or partially paid.

EMS provides out-of-hospital medical care to those with perceived urgent needs. It is a component of the overall health care system. EMS delivers care as part of a system intended to attenuate the morbidity and mortality associated with sudden illnesses and injury. The positive effects of EMS care are enhanced by linkages with other community health resources and integration within the health care system.

Description of the Profession by Provider Level
(excerpts from National Scope of Practice Model 2007, pgs 22-28)

EMS skills and knowledge represent a continuum of complexity and risk. As the licensure level increases, the knowledge required to practice safely, the skill complexity (the difficulty in acquiring and maintaining skill competency), and the potential for harm increase. Communities must assess their needs and the resources they are willing and able to invest in out-of-hospital emergency care.

The primary role of each EMS licensure level is outlined in the “Description of the Profession” sections. The language in the “Description of the Profession” and “Psychomotor Skills” sections may be helpful to States as they integrate the National EMS Scope of Practice Model into their laws or administrative regulations.

The Psychomotor Skills sections describe the minimum skill set associated with each licensure level. The Psychomotor Skills sections do not reference specific pieces of equipment or procedures, but rather, are written with more explanatory language. This is intended to minimize the need for changes to the EMS Scope of Practice Model as technology and medical science evolve. This approach also allows States a degree of latitude in how detailed they choose to be in defining specific psychomotor skills and procedures that will be allowed by the State for licensed EMS personnel.

Emergency Medical Responder (EMR)

The Emergency Medical Responder’s scope of practice includes simple skills focused on lifesaving interventions for critical patients. Typically, the Emergency Medical Responder renders on-scene emergency care while awaiting additional EMS response and may serve as part of the transporting crew, but not as the primary care giver.

In many communities, Emergency Medical Responders provide a mechanism to increase the likelihood that trained personnel and lifesaving equipment can be rapidly deployed to serious emergencies. In all cases, Emergency Medical Responders are part of a tiered response system. Emergency Medical Responders work alongside other EMS and health care professionals as an integral part of the emergency care team.

The Emergency Medical Responder’s scope of practice includes simple, non-invasive interventions to reduce the morbidity and mortality associated with acute out-of-hospital medical and traumatic emergencies. Emergency care is based on assessment findings. Additionally, the Emergency Medical Responder provides care designed to minimize secondary injury and comfort the patient and family while awaiting additional EMS resources.

A major difference between the lay person and the Emergency Medical Responder is the “duty to act” as part of an organized EMS response. In some systems, Emergency Medical Responders serve as a part of the crew on transporting EMS units; however, the EMR is not intended to be the highest level caregiver in such situations. They must function with an EMT or higher level personnel during the transportation of emergency patients. The scope of practice model of an EMR is limited to simple skills that are effective and can be performed safely in an out-of hospital setting with medical oversight.

After initiating care, the Emergency Medical Responder transfers care to higher level personnel. The Emergency Medical Responder serves as part of an EMS response system that ensures a progressive increase in the level of assessment and care.

EMR Psychomotor Skills
The following are the minimum psychomotor skills of the EMR:

  • Airway and Breathing
    • Insertion of airway adjuncts intended to go into the oropharynx
    • Use of positive pressure ventilation devices such as the bag-valve-mask
    • Suction of the upper airway
    • Supplemental oxygen therapy
  • Pharmacological Interventions
    • Use of unit dose auto-injectors for the administration of life saving medications intended for self or peer rescue in hazardous materials situations (MARK I, etc.)
  • Medical/Cardiac Care
    • Use of an automated external defibrillator
  • Trauma Care
    • Manual stabilization of suspected cervical spine injuries
    • Manual stabilization of extremity fractures
    • Bleeding control
    • Emergency moves
Emergency Medical Technician (EMT)

The Emergency Medical Technician’s scope of practice includes basic skills focused on the acute management and transportation of critical and emergent patients. This may occur at an emergency scene until transportation resources arrive, from an emergency scene to a health care facility, between health care facilities, or in other health care settings.

In many communities Emergency Medical Technicians provide a large portion of the out-of-hospital care. In some jurisdictions, especially rural areas, Emergency Medical Technicians provide the highest level of out-of-hospital care. Emergency Medical Technicians work alongside other EMS and health care professionals as an integral part of the emergency care team.

Emergency Medical Technicians’ scope of practice includes basic, non-invasive interventions to reduce the morbidity and mortality associated with acute out-of-hospital medical and traumatic emergencies. Emergency care is based on assessment findings. Additionally, Emergency Medical Technicians provide care to minimize secondary injury and provide comfort to the patient and family while transporting the patient to an emergency care facility.

An Emergency Medical Technician’s knowledge, skills, and abilities are acquired through formal education and training. The Emergency Medical Technician has the knowledge of, and is expected to be competent in, all of the skills of the EMR. A major difference between the Emergency Medical Responder and the Emergency Medical Technician is the knowledge and skills necessary to provide medical transportation of emergency patients.

The Emergency Medical Technician level is the minimum licensure level for personnel transporting patients in ambulances. The scope of practice is limited to basic skills that are effective and can be performed safely in an out-of-hospital setting with medical oversight and limited training.

The Emergency Medical Technician transports all emergency patients to an appropriate medical facility. The Emergency Medical Technician is not prepared to make decisions independently regarding the appropriate disposition of patients. The Emergency Medical Technician serves as part of an EMS response system, assuring a progressive increase in the level of assessment and care. The Emergency Medical Technician may make destination decisions in collaboration with medical oversight. The principal disposition of the patient encounter will result in the direct delivery of the patient to an acute care facility.

In addition to emergency response, Emergency Medical Technicians often perform medical transport services of patients requiring care within their scope of practice.

EMT Psychomotor Skills
The following are the minimum psychomotor skills of the EMT:
  • Airway and Breathing
    • Insertion of airway adjuncts intended to go into the oropharynx or nasopharynx
    • Use of positive pressure ventilation devices such as manually triggered ventilators and automatic transport ventilators
  • Pharmacological Interventions
    • Assist patients in taking their own prescribed medications
    • o Administration of the following over-the-counter medications with appropriate medical oversight:
      • Oral glucose for suspected hypoglycemia
      • Aspirin for chest pain of suspected ischemic origin
  • Trauma Care
    • Application and inflation of the pneumatic anti-shock garment (PASG) for fracture stabilization
Advanced Emergency Medical Technician (AEMT)

The Advanced Emergency Medical Technician’s scope of practice includes basic and limited advanced skills focused on the acute management and transportation of critical and emergent patients. This may occur at an emergency scene until transportation resources arrive, from an emergency scene to a health care facility, between health care facilities, or in other health care settings.

For many communities, Advanced Emergency Medical Technicians provide an option to provide high benefit, lower risk advanced skills for systems that cannot support or justify Paramedic level care. This is frequently the case in rural and volunteer systems. In some jurisdictions, Advanced Emergency Medical Technicians are the highest level of out-of-hospital care. In communities which utilize emergency medical dispatch systems, Advanced Emergency Medical Technicians may function as part of a tiered response system. In all cases, Advanced Emergency Medical Technicians work alongside other EMS and health care professionals as an integral part of the emergency care team.

The Advanced Emergency Medical Technician’s scope of practice includes basic, limited advanced and pharmacological interventions to reduce the morbidity and mortality associated with acute out-of-hospital medical and traumatic emergencies. Emergency care is based on assessment findings. Additionally, Advanced Emergency Medical Technicians provide care to minimize secondary injury and provide comfort to the patient and family while transporting the patient to an emergency care facility.

The Advanced Emergency Medical Technician’s knowledge, skills, and abilities are acquired through formal education and training. The Advanced Emergency Medical Technician has the knowledge associated with, and is expected to be competent in, all of the skills of the EMR and EMT. The major difference between the Advanced Emergency Medical Technician and the Emergency Medical Technician is the ability to perform limited advanced skills and provide pharmacological interventions to emergency patients.

The Advanced Emergency Medical Technician is the minimum licensure level for patients requiring limited advanced care at the scene or during transportation. The scope of practice model is limited to lower risk, high benefit advanced skills that are effective and can be performed safely in an out-of-hospital setting with medical oversight and limited training.

The Advanced Emergency Medical Technician transports all emergency patients to an appropriate medical facility. The Advanced Emergency Medical Technician is not prepared to independently make decisions regarding the disposition of patients. The Advanced Emergency Medical Technician serves as part of an EMS response system assuring a progressive increase in the level of assessment and care. The Advanced Emergency Medical Technician may make destination decisions in collaboration with medical oversight. The principal disposition of the patient encounter will result in the direct delivery of the patient to an acute care facility.

In addition to emergency response, Advanced Emergency Medical Technicians often perform medical transport services of patients requiring care within their scope of practice.

AEMT Psychomotor Skills
The following are the minimum psychomotor skills of the AEMT:
  • Airway and Breathing
    • Insertion of airways that are NOT intended to be placed into the trachea
    • Tracheobronchial suctioning of an already intubated patient
  • Assessment
  • Pharmacological Interventions
    • Establish and maintain peripheral intravenous access
    • Establish and maintain intraosseous access in a pediatric patient
    • Administer (nonmedicated) intravenous fluid therapy
    • Administer sublingual nitroglycerine to a patient experiencing chest pain of suspected ischemic origin
    • Administer subcutaneous or intramuscular epinephrine to a patient in anaphylaxis
    • Administer glucagon to a hypoglycemic patient
    • Administer intravenous D50 to a hypoglycemic patient
    • Administer inhaled beta agonists to a patient experiencing difficulty breathing and wheezing
    • Administer a narcotic antagonist to a patient suspected of narcotic overdose
    • Administer nitrous oxide for pain relief
Paramedic

The Paramedic’s scope of practice includes basic and advanced skills focused on the acute management and transportation of the broad range of patients who access the emergency medical system. This may occur at an emergency scene until transportation resources arrive, from an emergency scene to a health care facility, between health care facilities, or in other health care settings.

In some communities, Paramedics provide a large portion of the out-of-hospital care and represent the highest level of out-of-hospital care. In communities that use emergency medical dispatch systems, Paramedics may be part of a tiered response system. In all cases, Paramedics work alongside other EMS and health care professionals as an integral part of the emergency care team.

The Paramedic’s scope of practice includes invasive and pharmacological interventions to reduce the morbidity and mortality associated with acute out-of-hospital medical and traumatic emergencies. Emergency care is based on an advanced assessment and the formulation of a field impression. The Paramedic provides care designed to minimize secondary injury and provide comfort to the patient and family while transporting the patient to an appropriate health care facility.

The Paramedic has knowledge, skills, and abilities developed by appropriate formal education and training. The Paramedic has the knowledge associated with, and is expected to be competent in, all of the skills of the EMR, EMT, and AEMT. The major difference between the Paramedic and the Advanced Emergency Medical Technician is the ability to perform a broader range of advanced skills. These skills carry a greater risk for the patient if improperly or inappropriately performed, are more difficult to attain and maintain competency in, and require significant background knowledge in basic and applied sciences.

The Paramedic is the minimum licensure level for patients requiring the full range of advanced out-of-hospital care. The scope of practice is limited to advanced skills that are effective and can be performed safely in an out-of-hospital setting with medical oversight.

The Paramedic transports all emergency patients to an appropriate medical facility. The Paramedic serves as part of an EMS response system, ensuring a progressive increase in the level of assessment and care. The Paramedic may make destination decisions in collaboration with medical oversight. The principal disposition of the patient encounter will result in the direct delivery of the patient to an acute care facility.

In addition to emergency response, Paramedics often perform medical transport services of patients requiring care within their scope of practice.

Paramedic Psychomotor Skills
The following are the minimum psychomotor skills of the Paramedic:
  • Airway and Breathing
    • Perform endotracheal intubation
    • Perform percutaneous cricothyrotomy*
    • Decompress the pleural space
    • Perform gastric decompression
  • Pharmacological Interventions
    • Insert an intraosseous cannula
    • Enteral and parenteral administration of approved prescription medications
    • Access indwelling catheters and implanted central IV ports for fluid and medication administration
    • Administer medications by IV infusion
    • Maintain an infusion of blood or blood products
  • Medical/Cardiac Care
    • Perform cardioversion, manual defibrillation, and transcutaneous pacing
* Percutaneous means access via needle-puncture (or other approved puncture device) and DOES NOT include “surgical” access using a scalpel.

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