Comprehensive Study Guide for EMS Systems and EMT Basics and System and Paramedic Systems

Levels of EMS Training and the Integrated Care Team

• The EMS Team Hierarchy: Emergency Medical Services (EMS) functions as a unified team. While providers operate at different levels based on training, all levels are dependent on one another.
  • Emergency Medical Responder (EMR): Provides the most basic level of care (e.g., CPR, bleeding control).
  • Emergency Medical Technician (EMT): The backbone of the EMS system. Focuses on Basic Life Support (BLS).
  • Advanced EMT (AEMT): Adds intermediate skills such as starting IVs and administering a limited set of additional medications.
  • Paramedic: The highest prehospital level, providing Advanced Life Support (ALS).
• The Continuum of Care: The speaker initially describes care as a continuum, but notes it is actually characterized by distinct sets of rules and autonomy. Prehospital providers follow specific protocols that sometimes allow them more autonomy than hospital nurses (e.g., a paramedic may perform procedures a nurse cannot because the paramedic follows a specific book of protocols).
• The Transition of Care: Prehospital providers (First Responders, EMTs, Paramedics) initiate care and then hand the patient over to hospital staff (nurses and physicians).

Licensure, Certification, and the Interstate Compact

• Certification vs. Licensure:
  • National Registry: Upon completing the EMT course, students take the National Registry exam. Having a National Registry card proves a provider is certified and trained to a national standard.
  • State Licensure: A license is issued by a government agency (e.g., the State of Maryland). Providers must be licensed by the state in which they operate.
• The Interstate Compact: As of the date of the transcript, $28$ out of $50$ states in the United States have joined an interstate compact. This agreement allows states to accept the National Registry card as proof of training, though providers must still learn and follow the specific protocols and nuances of each state.
• Maryland Specifics:
  • In Maryland, obtaining a license requires passing a state-specific protocol exam.
  • Maryland CRT (Cardiac Rescue Technician): An older certification level in Maryland, equivalent in many ways to the AEMT. CRTs in Maryland can perform slightly more tasks than a National Registry AEMT, but the certification is often not recognized outside of Maryland (e.g., it is not recognized in Pennsylvania).

Detailed Scope of Practice

• Emergency Medical Responder (EMR):
  • Focuses on basic lifesaving skills: CPR, bleeding control, and $\text{AED}$ operation.
  • Often serves as the minimum requirement for ambulance drivers in some jurisdictions.
• Emergency Medical Technician (EMT):
  • Provides Basic Life Support (BLS).
  • Utilizes airway adjuncts and Automated External Defibrillators ($\text{AED}$).
  • Authorized to administer or assist with approximately $9$ specific drugs, including:
    • Tylenol ($\text{Acetaminophen}$)
    • Aspirin
    • Narcan ($\text{Naloxone}$) for suspected opioid overdoses.
• Advanced EMT (AEMT):
  • Authorized to start IVs and administer a selection of additional medications beyond the EMT level.
• Paramedic:
  • Provides Advanced Life Support (ALS).
  • Performs advanced procedures like endotracheal intubation and cardiac monitoring (EKG interpretation).
  • Paramedic training is extensive, often involving $1,000$ to $1,500$ hours of training (e.g., one specific class mentioned is $964$ hours plus internships).
  • Paramedics carry a drug box with approximately $35$ different medications.

Professionalism, Public Trust, and Ethics

• The "Bedroom" Metaphor for Public Trust: EMS providers are uniquely invited into the most private areas of people's lives. Unlike law enforcement, which may arrive uninvited during conflict, the public calls and invites EMS into their homes, their bedrooms, and even into their beds (e.g., when lifting a patient). This requires a high level of integrity because providers have access to vulnerable people and their valuables (e.g., a diamond ring on a nightstand).
• Higher Standards for Public Servants: EMS providers are held to a higher standard of conduct by the public. Any criminal activity by a provider is often reported in the media by their professional title (e.g., "Retired Trooper commits murder"), reflecting the weight of the public trust.
• Entry Requirements:
  • High school diploma or equivalent.
  • Proof of immunizations.
  • Successful background check and drug screen (crucial because providers handle controlled substances).
  • Valid driver's license.
  • Mental stability and the ability to maintain composure under high-stress/adrenaline-heavy situations.
• Professional Attributes:
  • Appearance: Looking professional (clean-shaven, in uniform) conveys competence and education to the patient.
  • Professional Demeanor: Maintaining a calm, collected, and empathetic attitude even during repetitive or frustrating calls.
  • Self-Care: Maintaining personal hygiene (e.g., showering before shifts) is part of professional responsibility to the crew and patient.

History and Evolution of EMS

• Military Origins: Much of prehospital medicine originated on the battlefield.
  • World War I: Introduction of volunteer ambulances.
  • World War II: Development of field care (bandages and bleeding control).
  • Korean War: Emergence of helicopter transport (popularized by the show "MASH").
• Civilian Evolution:
  • Development of tourniquets: Historically avoided due to limb-loss fears, but modern military evidence (Iraq/Iran conflicts) proved they save lives by stopping bleeding long enough for transport to hospitals.
  • 1971: Maryland State Police performed the first civilian medevac transport from a scene in the U.S.

Medical Direction and Control

• Medical Director: A physician who acts as a liaison between the medical community and the EMS system. Every provider operates under the Medical Director's license.
• Protocols: Written guidelines for patient care.
• Standing Orders (Offline Medical Control): Protocols that allow providers to perform specific actions without calling a doctor (e.g., CPR or giving aspirin for chest pain).
• Online Medical Control: Direct orders given by a physician over the radio or phone (e.g., seeking permission to give charcoal for poisoning).
• Treating with On-Scene Physicians: If a bystander physician offers help, they must generally follow EMS protocols. If they wish to provide care outside of protocols, they must assume full responsibility and accompany the patient to the hospital.

Modern EMS Initiatives and Operations

• Mobile Integrated Healthcare (MIH) and Community Paramedicine:
  • Aims to improve community health and reduce unnecessary ER visits.
  • Example: A community paramedic might visit a diabetic patient ("Fred") to help him organize a pillbox or address environmental triggers like cockroach infestations (a leading cause of asthma) by contacting social services or housing inspectors.
• Continuous Quality Improvement (CQI):
  • Just Culture: A system that holds individuals accountable while recognizing that errors are often opportunities for training rather than punishment.
  • Error Types: Errors are categorized as Rules-based, Knowledge-based, or Skill-based.
• Electronic Patient Care Reporting ($\text{ePCR}$): Transition from paper to digital records (e.g., using iPads or the "Epic" system). Modern systems can upload data (heart rate, blood pressure) directly from cardiac monitors to the patient report.
• 911 Dispatch Evolution: Shift from local phone lines (e.g., the historical "739-1111" number in Leitersburg) where a dispatcher would ring a literal bell or siren, to modern integrated GPS dispatching.
• EMS Finance: Systems are funded through various means, including fundraising (e.g., Bingo), soft billing (billing insurance but not the patient for the balance), and subscription services.

Educational Strategy: "See One, Do One, Teach One"

• This traditional medical school method is utilized in EMT training:
  1. See One: Watch the instructor demonstrate the skill.
  2. Do One: Perform the skill under supervision.
  3. Teach One: Explain and demonstrate the skill to a partner to solidify understanding.

Questions & Discussion

• Scenario: Standing Orders. An example of a standing order is $\text{defibrillating}$ a patient in cardiac arrest and starting CPR before contacting medical control.
• Scenario: Scene Safety. If hearing yelling and breaking glass at a domestic dispute, the EMT's highest priority is personal safety; they should retreat to a safe place until law enforcement arrives.
• Scenario: Qualifications. Operating under the influence of alcohol is a primary disqualifier for EMS certification.
• Scenario: Scope of Care. Determining that an emergency exists is always the first phase of the emergency patient care process.