EMT 1-1: Introduction to Emergency Care

Welcome to the Emergency Medical Technician
course based upon the Wisconsin 2012 EMT curriculum. This is the first module in which you will
receive an introduction to the field of emergency medicine. Once completed with this module, you should
be able to: Define emergency medical service (EMS) systems;
identify the importance of the National EMS Education Agenda for the Future as it pertains
to the EMT; differentiate the roles and responsibilities
of the EMT from other pre-hospital care providers; describe the roles and responsibilities related
to personal safety; discuss the roles and responsibilities of
the EMT toward the safety of the crew, the patient, and bystanders;
describe the process of critical thinking as it pertains to the roles and responsibilities
of the EMT; define quality improvement and discuss the
EMT’s role in the process; describe how the actions of one crew member
can affect those of others; define medical direction and discuss the EMT’s
role in the process; define the specific statutes and regulations
in Wisconsin regarding the EMS system; explain employer policies and procedures pertaining
to the EMT; and, identify the role of public health as it pertains
to the EMT. You should also be able to:
Assess areas of personal attitude and conduct of the EMT,
characterize the various methods used to assess the EMS system in your community, and
value the need for evidence-based research. As this presentation is provided to meet the
needs of various Wisconsin EMS training centers, several of the items contained within this
slide must be addressed directly with your training center. Each training center has local paperwork that
must be completed for program enrollment and/or course registration. Electronic accounts must be established with
the DHS EMS Unit (via their E-Licensing system) and the National Registry of Emergency Medical
Technicians (NREMT). The Department of Health Services EMS Unit
has a Training Permit Application form that must be completed through the E-Licensing
system and, along with that form, criminal background results from the Department of
Justice and DHS must also be submitted. Many programs require clinical rotations to
meet state-mandated competency requirements, which also means students must meet certain
health requirements, such as vaccinations and drug screenings, to participate in the
EMT program. There may be additional paperwork as well,
depending on the training center and local requirements. While the EMT curriculum used within the state
of Wisconsin is standardized across all the training centers, meaning the course description
should be similar between the training centers, each training center defines its own expectations
for student success. Regardless of where you are taking the EMT
course in Wisconsin, the Americans with Disabilities Act does apply, which requires training centers
to provide reasonable accommodation to you in the event of a recognized disability (which
may include learning disabilities). Given the health requirements contained within
most EMT programs, students must be able to perform essential EMT job tasks to participate
in the program. Unfortunately, students who are unable to
perform essential job tasks with or without reasonable accommodation will more than likely
be excluded from participation in the EMT program. Students also have the right to participate
in educational experiences in a harassment-free environment. Each training center should have policies
and procedures regarding harassing conduct. Please contact your training center for this
information. The state of Wisconsin uses the National Registry
of Emergency Medical Technicians’ cumulative testing process, which consists of both a
cognitive (written) and psychomotor (practical) test. Students must successfully complete the EMT
course (or program) at their training center to be eligible for NREMT testing. Once NREMT testing is successfully completed,
students must apply to DHS for their EMT license (through the DHS E-Licensing website). Your instructor should be able to provide
additional information regarding this process, as well as the other requirements denoted
within this particular slide. With our course overview completed, we can
delve into our overview of the EMS system by discussing the following topics in turn:
National Highway Traffic Safety Administration Technical Assistance Program Assessment Standards,
access to the system, education,
the health care system, hospital personnel,
liaison with other public safety workers, and
overview of the local EMS system. To know where one is going, it is often necessary
to know where you have been. As far as EMS is concerned, the field itself
is relatively young with origins in the 1960s. After seeing an increase in accidental deaths
resulting from motor vehicle accidents, Congress passed the National Highway Safety Act in
1966 to combat what was seen as a growing epidemic. Amongst other things, this legislation empowered
the United States Department of Transportation to develop EMS standards and assist the states
in their implementation, all with the goal of reducing deaths on our nation’s roadways. Congress also passed the National Emergency
Medical Services Systems Act in 1973 to provide grant funding to states in establishing their
respective EMS systems while also establishing national standards for those systems. These two pieces of legislation were the initial
building blocks to the EMS system we know today. The National Highway Traffic Safety Administration
(“NHTSA”) is very active through its Technical Assistance Program in providing guidance and
support to state EMS systems. The standards set forth by NHTSA include some
of the following: Each state must have enabling legislation
in place that creates its EMS system; there must be a lead EMS agency; a funding mechanism;
and, regulations, policies, and procedures that govern the state’s system. There must be a centralized coordination of
resources so that everyone within the state has access to basic EMS care and transport
to an appropriate facility in a licensed and properly equipped vehicle (which may include
helicopters and fixed-wing aircraft, in addition to ambulances). Ambulance attendants should be, at a minimum,
trained to the EMT level using a standardized curriculum taught by qualified instructors. Safe, reliable prehospital transportation
is required. In most instances, this means an ambulance,
but can also include aircraft. Seriously injured or ill patients must be
delivered in a timely fashion to the closest appropriate facility. An effective communication system must exist. This system must include a universal access
number (911) and a means for dispatch, transporting units, and receiving facilities to communicate
with each other. EMS personnel should participate in efforts
to educate the public about their role in the system, their ability to access the system,
and injury prevention activities. Medical direction is required for the system. EMS personnel function in the field under
the auspices of the medical director’s physician license and, as a result, the medical director
must be actively involved in all aspects of the patient care system. Each state must have enabling legislation
to develop, maintain, and evaluate a trauma system. Each system must also have a program in place
to evaluate its overall effectiveness as an EMS system. While this is just a cursory overview of the
NHTSA Technical Assistance Program standards, these standards are at the very core of statewide
EMS systems as they exist today. More information regarding Wisconsin laws
that impact EMS will be provided in the Medical Legal and Ethics module of this course. For most people, entrance into the state’s
EMS system begins with a phone call for help to a Public Safety Access Point (“PSAP”). All areas within Wisconsin have 911 service,
which allows a caller to access the EMS system through their phone by simply dialing 911. Just because 911 service is available, however,
does not mean it is enhanced 911. Enhanced 911 services provides the PSAP with
the location from which the call originates, helping reduce dispatch delays and errors. In areas without enhanced 911, the dispatcher
must rely on the caller for the location or address of the emergency. If the caller is not sure of their location,
this can add significant delay to the emergency response. Along somewhat similar lines, the Federal
Communications Commission (“FCC”) estimates that up to 70% of all 911 calls within the
United States originate from a cell phone. The FCC has rules requiring cell phone carriers
to route 911 calls to a local PSAP and provide a location for the caller, if possible. Depending on the age of the cell phone or
the area of the country, however, a triangulated or GPS location of the cell phone caller may
not be readily available. Believe it or not, there are areas of the
country that do not utilize 911, requiring individuals who need help to dial their local
emergency service provider directly, or contact the operator or directory assistance for the
service’s phone number. In such instances, there is obviously no enhanced
911, meaning that the caller must relay location information to the PSAP, which can lead to
errors and delays. As technology evolves, challenges for our
911 system also expand. Many areas within the state (and country,
for that matter) have access to voice over internet protocol (voice over IP) technology. This allows people to place telephone calls
over the internet. Because this system works very differently
from the wired land-line telephone system, it is possible to make a 911 call using voice
over IP technology where enhanced location services are not available. The FCC now requires voice over IP providers
to obtain a physical address from voice over IP subscribers, but it is incumbent upon the
voice over IP subscriber to update that information if he or she moves. Another problem is that these phones can move,
yet the data associated with them does not, meaning someone can take their voice over
IP phone with them on a trip, call 911 from that phone, and the call will be routed to
the appropriate PSAP for the address on file for that person, not to the PSAP based upon
his or her current location. Another emerging topic regarding 911 systems
is the availability of Emergency Medical Dispatch (“EMD”). Systems with EMD can provide pre-arrival instructions
to the caller to help mitigate the emergency even before a responding unit is dispatched. EMD is not required in all states, however,
including Wisconsin. Thus, an individual’s access to EMD services
will vary from jurisdiction-to-jurisdiction within the state. While education and training is a single component
of the NHTSA standards, it is obviously very important and has a substantial impact on
you, as an EMS student. Having trained, qualified emergency care providers
in the field is essential to a quality EMS system. In 1996, NHTSA and the Health Resources and
Services Administration (“HRSA”) published the EMS Agenda for the Future. This federally-funded position paper was created
by the National Association of EMS Physicians and the National Association of State EMS
Directors to create a common vision for the future of EMS within the United States. This paper stated that, “Emergency Medical
Services of the future will be community-based health management that is fully integrated
with the overall healthcare system. It will have the ability to identify and modify
illness and injury risks, provide acute illness and injury care and follow-up, and contribute
to treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution
of existing health care resources and will be integrated with other health care providers
and public health and public safety agencies. It will improve community health and result
in a more appropriate use of acute health care resources. EMS will remain the public’s emergency medical
safety net.” This common vision eventually gave rise to
five primary system components (which you can find summarized in the National EMS Education
Agenda for the Future: The National EMS Core Content, which is a comprehensive list of
skills and knowledge needed for out-of-hospital emergency care; the National EMS Scope of
Practice Model, which defines the different levels of practice within an EMS system; the
National EMS Education Standards, which replaced the former DOT National Standard Curricula
with documents that defined minimum terminal learning objectives for each level of practice;
National EMS Education Program Accreditation, which is managed by the Committee on Accreditation
of Education Programs for the Emergency Medical Service Professions [“CoAEMSP”]; and,
National EMS Certification, which is managed by the National Registry of Emergency Medical
Technicians [“NREMT”]). Combined, these documents and initiatives
have created a new groundwork for EMS within the United States, and numerous individual
states are slowly adopting different aspects of this new groundwork. (If you want more information, ems.gov has
a wealth of information as it pertains to EMS on a national level.) Within Wisconsin, 2012 marks the year of implementation
for these updated standards. In compliance with the National EMS Core Content,
the state of Wisconsin maintains the Emergency Medical Responder, Emergency Medical Technician,
Advanced EMT, and Paramedic levels. These levels are also recognized and supported
by the NREMT. Given existing legislation and regulations
within Wisconsin, the Intermediate (I-99) level is also recognized within the state,
although it would appear as though the level is being phased out by all but a few remaining
Intermediate services (NREMT recognized the level through December of 2012; effective
January 2013, NREMT no longer registers EMS providers at the Intermediate level). By application of state law, the EMT level
is the lowest level of licensure acceptable for an ambulance attendant. Individuals credentialed at the EMR level
may provide on-scene care within their defined scope of practice, but do not count as a member
of a legal ambulance crew within Wisconsin. The EMS system is actually part of the larger
health care system within this country. While EMS routinely interacts with hospital
emergency departments, it is important to recognize that providers must also be familiar
with trauma centers, burn centers, pediatric centers, poison centers, and other specialty
centers (such as cardiac centers, stroke centers, and mental health facilities), if they exist
within their area. Many jurisdictions also have community-based
residential facilities (“CBRFs”) designed to provide care to specialty patients in a
residential environment. There are also instances where individuals
with chronic health conditions have home healthcare providers that deliver routine care to them
within the confines of their residence. These healthcare providers can be home health
aides, certified nursing assistants, registered nurses, or even physicians, all with different
levels of medical education, training, and knowledge, yet still a part of that over-encompassing
health care system. EMTs are merely one type of healthcare professional. When transferring patient care, EMTs will
routinely interface with physicians (who have the greatest flexibility in treating patients)
and registered nurses (who can perform numerous skills and administer any number of medications
with a physician’s orders) to other health professionals who have more specialized roles,
such as an emergency department technician, registration clerk, phlebotomist, respiratory
therapist, and so on. It is important to recognize and understand
these different roles as EMS providers must ensure patient care is assumed by someone
with a higher-level of licensure to care for the patient, which typically means a registered
nurse or physician. The EMS system also works with numerous other
systems and agencies. As an EMT, you will find yourself working
with local law enforcement, possibly state or federal law enforcement, emergency management
workers, public health officials, public works employees, and utility company personnel. The anatomy, so to speak, of your local EMS
system can vary from jurisdiction-to-jurisdiction. Some communities receive EMS services through
private ambulance providers or hospital-based EMS. Other areas utilize municipal services which
may or may not be fire-based. PSAP access may be through a local police
department, a county dispatch service, or some other facility. The hospitals and specialty facilities available
within an area or region fluctuate greatly as well, depending on your location within
the state. Areas with higher populations typically enjoy
more options for definitive healthcare. The metro Milwaukee area, for instance, has
a Level I trauma center, a pediatric hospital, a burn center, hospitals with bariatric chambers,
and numerous other hospitals, many of which offering specialty care for victims of strokes
or cardiac events. Sparsely populated areas, on the other hand,
typically have few options regarding definitive care facilities. Some areas have ample paramedic coverage while
other areas make substantial use of Emergency Medical Responders and EMT transporting ambulances. Some services are staffed by volunteers, others
have full-time staff, and there are different combinations of the two. Your local training center can provide additional
information regarding EMS services within its area. There are obviously tremendous differences
between services within the state, how they function, and the level of care provided. Regardless of where an EMT serves, that individual
EMT is still an EMS professional. As such, the professional EMT must be familiar
with his or her roles and responsibilities, which are the same across the state. The EMT must be able to gather, analyze, and
process information to determine an appropriate course of action. The EMT must be able to accurately and appropriately
generate, convey, and protect documentation regarding patient care. The EMT must also maintain his or her professional
credentialing. These are important topics and we will evaluate
each one in turn. An EMT must be able to think critically. This means the EMT must gather, analyze, and
process information to determine the best, most appropriate course of action to manage
the patient’s complaints. This may sound simple, but can be very complicated
given numerous factors that must always be a part of that decision-making process. An EMT must first consider his or her own
personal safety. Simply stated, an injured or dead EMT cannot
save lives. Actually, an injured EMT can complicate a
scene considerably because that injured EMT could possibly be another patient that must
be treated. EMS providers are not trained to mitigate
dangerous situations, such as armed people or hazardous materials incidents. Scene safety is of paramount importance for
the EMT. Keeping one’s self safe is important, but
an EMT must also be mindful of hazards to others, including members of his or her own
crew, the patient, and other bystanders. The last thing an EMT needs when treating
a patient is more patients requiring attention at the same time. An EMT must be mindful of scene hazards and
should take steps to keep others safe. Depending on the nature of the call and the
way in which resources are dispatched, a new EMT may very well find him or herself responsible
for providing scene leadership. As an example, the first ambulance crew on
the scene of a multiple vehicle accident must assert authority and leadership for the members
of the public involved in the accident, as well as others that happen to be present at
the scene as well. It may be necessary to triage patients, direct
“walking wounded” to a waiting area, or direct bystanders to move away from a hazardous
area. It does not matter if the EMT is a seasoned
veteran or fresh out of school, the public will automatically view you as a trained professional
who can effectively mitigate whatever emergency arises. With all of that on your mind, one must not
forget to actually assess the patient. The EMT must ask questions, obtain vital signs,
collect information from family members or bystanders, and assimilate any other data
pertinent to that patient’s condition, all with the goal of developing a differential
diagnosis for the patient. Once that diagnosis is made, the EMT must
then develop and implement a treatment plan for the patient. Doing that is not enough, however, as the
EMT must constantly reassess the patient and the effectiveness of any treatment provided. In many instances, you will find that the
patient needs emotional support as well as the physical treatment you are providing. This support may be necessary for that patient’s
family, friends, or other responders as well. It is rare to find a patient sitting at the
curb waiting to step onto the ambulance. Far too often, the patient could not be in
a more difficult location to navigate and treat. When approaching the patient, the EMT must
also gauge the best way in which to convey the patient to the ambulance. Maybe a stretcher will work fine; maybe it
will not. Quarters may be cramped and the EMTs have
to physically move the patient to an area where the patient can be transferred to a
stair chair. Maybe blankets will be necessary to slide
a patient to an open area. Anyone in EMS long enough may have even seen
the local fire department called to help extricate a patient from his or her own house. It is routine for EMS providers to lift and
move patients, which takes this discussion right back to point number one and personal
safety. Proper lifting mechanics and the use of appropriate
equipment is a necessity to save your joints, muscles, and back from discomfort, fatigue,
and possible injury. Your concerns are not over once the patient
is in the back of the ambulance. Aside from the constant reassessment that
must occur, it is important to transport the patient as safely as possible while also gauging
the seriousness of the patient. You will have to follow your protocols to
determine whether the patient should be transported with lights and siren, or if an easy ride
in to the hospital is just fine. If you are the individual driving the ambulance,
you must drive defensively, even with lights and siren activated, keeping an eye on other
traffic as well as nearby pedestrians. Being involved in a motor vehicle accident
is not just inconvenient, it risks the well-being of your patient, your crew, and the public. Better for the transport to take a little
longer than to have it stopped all together due to an ambulance crash. Once at the hospital, care of the patient
must be transferred to appropriate staff. That means more patient movement, in addition
to providing both verbal and written reports to appropriate hospital staff so that adequate
care of the patient is continued. In some instances, your communication with
the hospital may result in a direct admit of the patient to a specialty unit, which
makes your transfer of care and reporting even more critical. Throughout the entire process, the EMT must
also be prepared to work with other professionals to ensure safety for everyone involved as
well as continuity of care for the patient. This means working with law enforcement, emergency
management, other responders (including firefighters, department of public works employees, and
utility company personnel), home healthcare providers, and various medical personnel. When discussing critical thinking, it is necessary
to drill down a little further into the aspect of patient safety because it is recognized
as one of the most urgent challenges facing the healthcare system. Avoiding treatment and medication errors is
paramount in the EMT’s mantra to do no harm. In discussing prehospital errors, several
areas have been identified as being high-risk activities where errors are more likely to
result in greater harm to the patient. One such activity is patient movement. When in your care, patients are literally
placing their well-being in your hands. Dropping patients can result in significant
injury to the patient as they are commonly unable to protect themselves against a fall
or the resulting impact. This can occur during the hand-off of the
patient to the receiving facility as well, especially when moving the patient from the
ambulance cot to the hospital gurney. Communication issues are also problematic,
especially when important information pertinent to the patient’s condition or treatment
is not adequately conveyed or received. We already briefly discussed ambulance crashes,
which place more than just the patient at risk; and, improper or the complete lack of
spinal immobilization when indicated can have dire consequences for a patient with traumatic
spinal injury. Patient care errors can be broken down into
three specific categories. First, there are skills-based failures, where
the provider performs a skill improperly. Provider fatigue can lead to such a failure,
which can be common for EMS professionals working during evening hours, especially if
awakened from sleep for a response. Skills can also be performed negligently as
well, commonly due to a lack of adequate training, which is obviously very preventable. A second reason for errors are rules-based
failures. These types of errors occur when our policies,
procedures, or protocols do not adequately recognize or identify a specific patient presentation
or problem, or the proscribed treatment is incorrect. This has been known to occur as science and
EMS research improves and we realize past practices were actually not based on sound
science and data. One such example pertinent to the EMT level
is the former practice of hyperventilating head injury patients thinking the practice
would reduce cerebral edema. As it turns out, that practice is suspected
to have done more harm than good by affecting cerebral perfusion and the body’s acid-base
balance by removing carbon dioxide at too high a rate. The third reason for a treatment error is
a knowledge-based failure. These failures occur when the provider encounters
something that is simply outside the scope of his or her knowledge base. While contacting medical control in such an
instance would be of tremendous benefit, there are some providers who choose not to utilize
online medical control and treat the patient without actually knowing whether or not the
treatment is appropriate. An even greater tragedy is when a provider
has a mistaken understanding of the underlying knowledge. These failures are more dangerous in that
the provider will commonly not even realize he or she does not know something, thus missing
the importance of seeking help or trying to increase his or her pertinent knowledge in
the subject matter. So, if we are able to identify our high-risk
activities and we know the three ways that errors can happen, we should be able to proactively
prevent those known errors from occurring in many instances. This is commonly accomplished through two
different mechanisms, environmental controls and individual provider initiative. Such environmental controls include making
sure your service has clear protocols, that there is adequate light in which to work (even
at a dark scene), there are minimal interruptions during patient interactions (at least as much
as we can control in the field), and all medications are organized well and packaged appropriately
to quickly and easily identify the medication as well as the dosage included within the
packaging. Individual initiative includes self-reflection,
where the EMT actively tries to identify deficiencies in his or her knowledge-base and strives to
be a lifelong learner within the profession. As part of this reflection, the EMT must commonly
question his or her assumptions to either validate those assumptions or recognize that
they may be flawed. Along those lines, the provider may also want
to ensure he or she addresses personal bias regarding patients as well as treatment modalities. For instance, someone providing routine care
in an urban area with a high proportion of people considered to be of low socioeconomic
status may slowly become jaded regarding those patients who commonly lack the education or
resources necessary to understand or receive appropriate health care, which can impact
the care provided by that EMT. Interfacing with individuals who have a different
value system, especially given cultural and religious beliefs different from the provider’s,
may have the same result as well. As EMS and the services provided by EMTs continue
to expand, so too does the knowledge base required of those EMTs. There is a point at which it is unrealistic
for an EMT to remember every single protocol, drug dosage, or acronym used to assist the
memory. In those instances, the use of decision aids
(such as treatment cards or handbooks) can be a valuable tool. Lastly, any provider who is unsure or suspects
a gap in his or her knowledge base should simply ask for help. No EMT is expected to know everything. The EMT is expected to recognize when he or
she does not know something, however, and seek assistance. Utilize your fellow EMS professionals, ED
staff, and medical control. Remember that we are all part of a larger
healthcare system with the goal of providing positive outcomes for our patients. Patient care is a team effort. Do not hesitate to tap into those team members
for help and instruction when necessary. Aside from caring for our patients, we also
owe them a duty to properly and adequately document their interactions with us. Our documentation becomes part of that patient’s
permanent medical record and also plays a vital role in the continuity of that patient’s
care from the back of the ambulance to the ED to wherever that patient goes after that. Despite the fact that Wisconsin law requires
submission of the ambulance report to the receiving facility within 24 hours, EMS providers
should consider conveying the patient report to the receiving facility along with the patient
to ensure the documentation is available for the receiving staff to maintain a proper continuation
of patient care. Additionally, the data collected is used to
perform continuous quality improvement (“CQI”) initiatives that can also help show the positive
impact of a particular service within the community. In Wisconsin, that data is also used as part
of a statewide monitoring system to recognize possible pandemics and other public health
trends as early as possible. Keep in mind as well that the documentation
generated by an EMT can serve a legal purpose well beyond the timeframe in which they are
interacting with that EMS crew. Years from the date of the call, EMS documentation
may play a key role in a lawsuit. That lawsuit may be the only opportunity for
the patient to be compensated for serious injuries, or to ensure the wrongdoer in the
case is adequately punished, so to speak, and changes his or her behavior to avoid injuring
someone in a similar fashion at some other time. If you or your ambulance service are a party
to that lawsuit, your paperwork takes on even greater importance to yourself and your service. Given the application of patient confidentiality
laws, such as HIPAA and state law provisions (which will be discussed in another module),
the EMT must also respect and protect patient confidentiality and his or her protected health
information. In addition to gathering, documenting, maintaining,
and protecting patient data, the EMT must also serve as an advocate for the patient,
especially for patients who lack the capacity or resources to serve as their own advocate. In most instances, this means adequately conveying
the gravity of the patient’s condition to the receiving medical facility so that care
is delivered appropriately and quickly when time is of the essence. While last on the list of roles and responsibilities,
it is by no means the least of them. Maintaining certification and, more importantly,
licensure is paramount for the EMT. Without state licensure, you cannot practice
as an EMT and, if you cannot practice, everything else previously discussed becomes a moot point. Within Wisconsin, maintaining your EMT license
is a personal responsibility that cannot be delegated to your parents, spouse, service
director, or anyone else, for that matter. You and you alone are responsible for ensuring
you meet the requirements for licensure and subsequent renewal. E-Licensing is the electronic, internet-based
service by which DHS issues and manages EMS licenses in Wisconsin. If you have not already, as a Wisconsin EMT
student you will have to utilize the E-Licensing system to obtain a training permit to be used
within this EMT program. (Without that permit, you cannot participate
in clinical or field experiences, which are required for successful program completion,
regardless of the training center at which you are attending.) You will have to provide and upload criminal
background information, along with other supporting documentation to obtain that training permit. By deciding to become an EMT, you have already
dedicated yourself to the being a lifelong learner. EMS licenses in the state expire every June
30th of the even-numbered year. To maintain your EMT license, you must complete
mandated refresher continuing education within the prior biennium. If you choose to utilize the state’s flexible
refresher option, that means keeping track of all continuing education and maintaining
the documentation necessary to validate it for the E-Licensing system. You must also ensure your healthcare provider
CPR credential is maintained. As a part of the refresher process, you will
be expected to pass a written and practical test within every biennium. Maintaining your knowledge base and practical
skills is essential to not only provide safe and effective patient care, but is also necessary
to maintain your license. It is also important to recognize the difference
between National Registry credentialing and Wisconsin state licensure. The two are not the same. As a part of the initial EMT licensing process,
you will be taking the National Registry examination. If you are successful in your practical and
written tests, you will become a Nationally Registered EMT. Your status as a Nationally Registered EMT
does not allow you to practice as an EMT within the state of Wisconsin, however. You must still apply for and receive an EMT
license issued by the EMS Unit of the Wisconsin Department of Health Services. Once licensed within Wisconsin, it is up to
you whether or not to maintain your National Registry credentialing. Maintaining National Registry certification
is not required to maintain your Wisconsin EMT license. With that being said, however, you will have
to be Nationally Registered if you ever want to teach for an EMS training center. Additionally, providers maintaining their
National Registry certification may use that credential to renew their Wisconsin EMS licenses. The criteria for renewing your National Registry
includes completion of a state-sanctioned refresher plus continuing education hours. There is also an option to renew your National
Registry credential by challenging the cognitive computer-based adaptive test. Please be aware that your National Registry
expiration date is not the same as your Wisconsin EMS license expiration date. Also, renewing your National Registry credential
does not automatically mean you have a Wisconsin EMS license. You must still apply for your Wisconsin EMS
license by June 30 of every even-numbered year through the state’s E-Licensing system. For more information on National Registry
certification and renewal requirements, please visit nremt.org. As a part of obtaining initial licensure and
maintaining that licensure, you must also be cognizant of the implications of criminal
activity, which also includes drunk driving. DHS must approve all EMS student training
permits as well as non-student licenses and criminal backgrounds substantially related
to the profession of EMS can prevent a person from being licensed. Some common criminal histories that can prove
problematic include drunk driving, retail and other theft, possession of controlled
substances, crimes against children, sexual assault, domestic violence, and even disorderly
conducts (depending on the nature of the conduct). As an EMT, you will have access to people’s
homes, their personal/private property, and different medications (including narcotics). The public will imbue you with a significant
amount of trust and anything in your background that undermines that trust can prove to be
a problem for you, your service, and the EMS system in general. If you have a criminal background, it does
not mean an automatic bar to becoming an EMT as DHS can also issue conditional permits
and licenses. What is important to keep in mind, however,
is that you will be functioning within the scope of the public trust and your background
can become a matter of public scrutiny, especially if there is an allegation of impropriety filed
against you or your service. This criminal background review occurs every
two years when you renew your license, so just because you do not have a criminal background
now does not mean you will not have any problems in the future if you are someday convicted
of a crime that is substantially related to the profession of EMS. One other aspect of your professional responsibility
to maintain your EMS license and credentialing is that late fees apply to renew your license
and NREMT credential if you do not complete that process by the proscribed deadline date
and your license or NREMT credential enters a lapsed status. If the lapse progresses beyond a specific
amount of time, it may be necessary for you to complete some additional requirements beyond
paying a simple late fee before your license or credential will be renewed. In the case of the NREMT, this may mean challenging
the cognitive or psychomotor examinations, or both. For your state license, it may become necessary
to retake a full EMT course before another license will be issued (again, dependent on
the length of time associated with the lapse). Also keep in mind that a lapsed EMT license
means you cannot practice as an EMT in the state during the time period associated with
that lapse. Besides the obvious roles and responsibilities
we already discussed, an EMT must also possess certain professional attributes. These attributes go well beyond the ability
to critically think, perform skills, adequately document, and maintain credentialing by striking
at the core of the EMT. These attributes are a reflection of your
personal value system and behaviors; your morals, ethics, professionalism, and integrity. The patient’s first impression of you as
provider will be based upon what they see as you walk through the proverbial door. Your appearance must be neat and clean. Even if you are functioning on a volunteer
service without a uniform requirement, it is still important to present with a positive
image. Your presence on that scene should not be
a source of angst for the patient. How you present yourself, both aesthetically
and otherwise is so very important. While we already discussed the need to maintain
your education and training, there is a difference between the EMT who does the absolute minimum
to maintain his or her credentialing, and the EMT who understands the vital importance
of such activities to being an EMS professional. The EMT who actively seeks opportunities to
learn and improve truly recognizes the benefit such activities provide. With the understanding that we must first
keep ourselves safe (remember that dead heroes do not save lives, so to speak), the professional
EMT places the needs of the patient above all else. For example, choosing a specific transport
destination because they have better snacks or because it is closer, meaning the EMT can
be back home in bed sooner, are extraordinarily bad practices, especially when the patient
would benefit from going to a different facility, even if the food is not as good or the return
trip to the station takes longer. Having the patient with chest pain walk to
the ambulance because the crew does not want to go through the work of carrying the patient
down some narrow stairs on a stair chair is also a bad practice, bordering on professional
malpractice. Quality EMS providers go above and beyond
to care for their patients, even if it is inconvenient or difficult. The patient’s needs always come first. Another desirable professional attribute is
for the EMT to be current and active within the profession. This means staying involved in the EMS system,
which extends well beyond your provider’s service area. Both statewide and nationwide periodicals
are available within the EMS profession. Within Wisconsin, there are regularly scheduled
meetings of vital EMS groups, such as the State EMS Board, the WTCS EMS Training Centers,
Statewide Trauma Advisory Committee (STAC), Regional Trauma Advisory Committees (RTAC),
and the Physicians Advisory Committee (PAC). Information regarding these open meetings
are commonly available through the DHS EMS, WTCS EMS, or other websites. Your local area may also have regional meetings
of your local service providers. There are also numerous conferences and meetings
organized by non-governmental agencies as well, both within the state as well as nationally. It is understood that time comes at a premium
and many of our volunteer EMS providers within the state lack the resources or time to participate
in many of these events. It is still encouraged to browse EMS websites,
subscribe to trade periodicals, and attend meetings or events when possible to stay involved
within the profession. Given your enrollment in an EMT course, you
are a part of the EMS profession. Being involved is best way to ensure your
voice is heard when decisions are made that impact not only you, but the EMS system in
general. Lastly, it should go without saying that,
as an EMT, you must behave professionally at all times. Once you have your EMT license, you are no
longer a private citizen of little interest to the public and the media. If your professionalism slips, even when off
duty, you will be identified by the media as an EMT with whatever service employs you
or with which you are a volunteer. The public holds you to a higher standard,
as well they should. Being professional at all times means functioning
with integrity; being empathetic for your patients. You must be motivated in your own practice
of EMS. Also be confident in your abilities; the last
thing a patient wants is an EMT who appears to be scared, unsure, or panicked. The pace of life in general seems to have
accelerated in our modern society, and time management is of paramount importance as many
providers within the state must juggle their families, jobs, recreational pursuits, and
their EMS careers (even if that career is a volunteer one). Maintain a healthy work-life balance, but
also ensure you spend enough time to maintain your competence in the profession for the
benefit of your patients and the public you serve. Work together as a member of a team and do
so diplomatically, not abrasively. Be respectful of those team members, in addition
to your patients, their family members, the public, and other healthcare workers. Lastly, remember to be an advocate for your
patients, especially when they are unable or ill equipped to advocate for themselves. Another important component of any EMS system
is that of quality improvement. Quality improvement is defined as a system
of internal and external reviews and audits of all aspects of an EMS system so as to identify
those aspects needing improvement to assure that the public receives the highest quality
of prehospital care. Stated another way, your EMS service wants
to identify and rectify problems or deficiencies within its service well before it negatively
impacts patient care. This is obviously a very important facet of
maintaining an EMS service. As an individual EMT, you will play an important
part in these activities. Accurate, quality documentation is so very
important in continuous quality improvement (“CQI”) activities. This documentation not only follows the patient
during his or her care, but it is also used by your medical director and service director
to conduct CQI reviews. Related to your documentation are the CQI
activities of run reviews and audits. It is incumbent upon the service and its medical
director to ensure patients are treated properly and appropriately while in the care of its
EMS personnel. Compiling cumulative data from run reports
is also important to identify system-wide trends and possible deficiencies. Incomplete run reports and poor documentation
inhibit these efforts significantly. Feedback from the patients themselves, as
well as receiving hospital staff, is also important in conducting CQI activities. Our perception is our reality; it is helpful
to know how your patients felt about the care they received. The same can be said about hospital staff
that assumes patient care from the ambulance crew. Aside from service-coordinated CQI activities,
individual providers must also take an active role in quality improvement activities. That begins with ensuring adequate preventative
maintenance is performed. Practicing as an EMT in the field requires
the use of specialty equipment, all of which must be in good, working order. Ensure your defib has fully charged batteries. The ambulance should have plenty of fuel. Make sure all equipment is properly cleaned
and sanitized. Remove outdated medical supplies and medications
from service. As already discussed, it also imperative that
EMS providers seek continuing education and maintain their skills. That is how EMS providers maintain proficiency
and preparedness to mitigate emergencies for the benefit of our patients. If it is not already apparent, medical direction
from a qualified physician is a vital component of any EMS system. Within Wisconsin, EMS providers function under
authority delegated by their respective service’s medical director. Ultimately, the medical director for an EMS
service is a state-licensed physician responsible for the clinical and patient care aspects
of that service. Every ambulance provider in the state must
have a medical director identified. It is also important for that medical director
to be active and involved within that service. The role of medical director is not one of
a mere rubber stamp, so to speak. The medical director is integral in providing
and validating continuing education, as well as performing CQI activities. The terms medical direction and medical director
are sometimes used interchangeably, but they are two separate things. A medical director is a single physician responsible
for the clinical and patient care aspects of an EMS system. Medical direction is something a little more
broad, if you will. Providers must have access to medical direction
at all times, including evenings, weekends, and holidays, 24 hours a day, seven days a
week. There are actually two types of medical direction,
off-line and on-line. Off-line medical direction consists of written
protocols and standing orders. They are called off-line because the provider
does not need to be on-line or in contact with medical direction to perform as directed
by those protocols and standing orders. Inversely, there is also on-line medical direction
in which the EMT must make live contact with medical direction, commonly by radio or telephone,
to provide a specific treatment or perform a specific skill. Whether a treatment or skill is considered
to be off-line or on-line is a decision made by the service’s medical director. On-line medical control may also modify off-line
protocols, if necessary or prudent. Medical direction may not change or add to
the EMT’s scope of practice as defined by DHS, however. Given the need for on-line medical control,
it is apparent that no one physician can provide that type of commitment to a service. As a result, the medical director typically
works with the service to identify a healthcare entity, such as a hospital, to serve as medical
direction for a service. To reiterate, a special relationship exists
between the EMT and his or her medical director. The EMT is the designated agent of the physician
and care rendered in the field by the EMT is considered to be an extension of the medical
director’s authority as a licensed physician within the state. Each state has its own laws that impact EMS
within the state, and Wisconsin is no exception. There are numerous state laws that apply to
EMS in Wisconsin. The first is Wisconsin state statute, chapter
256. This law establishes and defines EMS in the
state. Because the state legislature knows very little
about EMS and its functioning, it has delegated authority to DHS for the promulgation of rules
pertaining to the functioning of EMS within the state. DHS 110 is the administrative rule in Wisconsin
that defines how the EMS system functions within the state. In addition to these major legal provisions,
there are also laws pertinent to patient confidentiality, patient autonomy, mandatory abuse reporting,
protective custody, and other facets of emergency care. Various labor and employment laws may apply
as well. Chapter 256, DHS 110, and these other provisions
will be discussed in greater depth by another module in this course. In addition to state and other provisions,
your employer will have policies and procedures that impact your employment or volunteerism. Many of these provisions may have nothing
to do with providing emergency care. Rather, they define your wages, hours, working
conditions, benefits, and other employment issues. Because every EMS agency is different, there
is no way to discuss specific policies and procedures within an educational setting such
as this. Just be aware that your EMS service will have
expectations regarding your performance and involvement with which you must comply. As EMS evolves, it becomes increasingly important
for decisions to be made based on data and evidence. Traditionally, medical practice was based
upon medical knowledge, intuition, and judgment. It was considered to be more art than science. While those components will probably always
remain a part of providing medical care, there is an increasing need to ensure the care we
are providing as EMS professionals has some basis in science as well. As medical research is conducted, we learn
more about the human body and the pathophysiology of various disease processes, which then impacts
the treatment we provide. Ultimately, high-quality patient care should
focus on procedures proven useful in improving patient outcomes. For too long, EMS has treated patients based
on tradition and past practice. The challenge is that there is a relative
lack of prehospital research available. Things are difficult to control in an emergent
setting and it is not always possible to obtain consent from emergency patients to participate
in important research. We are beginning to see that change, however. American Heart Association standards for CPR,
for instance, have been profoundly impacted by scientific research. The first step in using evidence-based decision-making
techniques is to first formulate a hypothesis, to identify something that just does not seem
right and try to develop other alternatives. Once the subject is defined, then perform
a medical literature review to see what body of knowledge already exists on the topic. It may be possible that someone else already
had the same idea and studied it. If there is research already available, take
a look at the data with a critical eye. Is the data valid and reliable? If not, or there is no significant research
available, it may be prudent to explore the possibility of a research project. Once the evidence is available, whether through
a comprehensive literature review or by conducting a research study, determine whether or not
the evidence supports a change. Again, the goal is improved patient outcomes. EMS providers want to provide treatments that
actually help patients. This is another reason why documentation is
so important. The aggregate data generated by proper documentation
across a service, region, or a state can be very powerful in helping to make some of these
evidence-based decisions that are pertinent to patient treatment and outcomes. Earlier it was stated that EMS systems also
contain a public health component. Within the next few slides, we will explore
the role of public health; public health laws, regulations, and guidelines; and, the interface
between EMS and public health. Public health can mean different things to
various people. For the purpose of this course, we will consider
public health to be a system by which the medical community oversees the basic health
of a population. The United States Department of Health and
Human Services defines the mission of public health in America to promote physical and
mental health while also preventing disease, injury, and disability. Keep in mind that public health is very different
from individual care. Public health speaks holistically about the
general population and also recognizes that the needs of the population occasionally outweigh
the needs of an individual. While we are all familiar with numerous public
health initiatives, some have been a part of our lives for so long that we take them
for granted and forgot how things were before they were initiated. Some examples include: widespread vaccinations,
clean drinking water, sewage systems, declining infectious disease, fluoridated water, tobacco
use cessation, and prenatal care. Public health agencies exist at virtually
all levels of government, from the federal level down to local municipalities, in some
instances. The graphic on this slide comes from the United
Stated Department of Health and Human Services to illustrate the process by which that agency
approaches its role in public health. Given various federal, state, and local provisions
pertaining to public health, defining all public health laws, regulations, and guidelines
is not possible as those laws, regulations, and guidelines may vary from jurisdiction-to-jurisdiction. As an EMT student, just be aware that public
health is governed by numerous laws and regulations, some of which have a direct impact on EMS. EMS is commonly held to be a public health
system. EMS provides a critical public health function
by providing care and treatment out in the public, with the ability to transport those
individuals to definitive care facilities. Some public health services may even be incorporated
into your service provider’s system, such as providing wellness checks or immunization
services. EMS also routinely collaborates with local
public health agencies. You will find that EMS is actively involved
in numerous public health initiatives, such as injury prevention activities. Encouraging the use of safety equipment or
educating the public on car seat safety, seat belt use, drunk driving awareness, fall prevention,
fire prevention, and injury surveillance are just some examples of public health injury
prevention initiatives supported throughout the EMS community. EMS also has some recognized roles within
public health, such as health prevention and promotion. It is becoming more common for EMS agencies
to take a primary role within the community at large to prevent disease development through
vaccination and education programs. When those efforts fail, EMS is there to mitigate
complications and attempt to stem the progression of disease. Many communities across the country have EMS
services that even provide health screenings, especially for individuals who are unable
to seek care from a private physician. Another important role for EMS in public health
is disease surveillance. EMS providers are first line caregivers and,
as a result, may recognize trends in communicable diseases before anyone else. Within Wisconsin, all ambulance documentation
is required to be submitted to the state, which maintains a database that generates
“heat maps” identifying areas where communicable diseases may be flourishing. Monitoring of this data is vital to catch
and stop the spread of pandemics. It should now be readily apparent to you that
EMS is by no means a simple profession. There are many facets to EMS and the licensed
EMT must understand how the system works and his or her role within that system. Given your completion of this module, you
should now be able to: Define emergency medical service (“EMS”)
systems; identify the importance of the National EMS
Education Agenda for the Future as it pertains to the EMT;
differentiate the roles and responsibilities of the EMT from other pre-hospital care providers;
describe the roles and responsibilities related to personal safety;
discuss the roles and responsibilities of the EMT toward the safety of the crew, the
patient, and bystanders; describe the process of critical thinking
as it pertains to the roles and responsibilities of the EMT;
define quality improvement and discuss the EMT’s role in the process;
describe how the actions of one crew member can affect those of others;
define medical direction and discuss the EMT’s role in the process;
define the specific statues and regulations in Wisconsin regarding the EMS system;
explain employer policies and procedures pertaining to the EMT; and,
identify the role of public health as it pertains to the EMT. You should also be able to:
Assess areas of personal attitude and conduct of the EMT,
characterize the various methods used to assess the EMS system in your community, and
value the need for evidence-based research. That concludes your introduction to emergency
medical care. Please contact your course instructor with
any questions you may have. This presentation was created by Waukesha
County Technical College with grant funding from the Wisconsin Technical College System.

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