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Provider Nomenclature
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Recently the nomenclature for prehospital providers was standardized nationwide to ensure consistency from one state to another.1,18 There are two levels of response in the prehospital setting: BLS and ALS.18 EMRs, formerly known as First Responders, and emergency medical technicians (EMTs), formerly known as EMT-Basics, provide BLS care in the EMS system.18 These providers receive training for scene response and initiation of basic life support such as CPR.18 EMTs have fundamental knowledge to provide patient care and transportation, and they make up the majority of the nation's prehospital providers.18
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Advanced emergency medical technicians (AEMTs) and Paramedics provide ALS care.18 AEMTs were formerly known as either EMT-Intermediates, EMT-85s, or EMT-99s.18 AEMTs have additional training to provide ALS care both on scene and during transport including advanced airway management and the administration of medications.18 Approximately 7% of prehospital providers are Advanced EMTs.19 Paramedics, formerly known as EMT-Paramedics, are allied health professionals who have undergone extensive training to enable them to provide ALS care to critically ill patients.18 Approximately 31% of prehospital providers in the nation are paramedics.19
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In general, the amount of EMS provider training parallels their scope of practice as outlined in the National EMS Scope of Practice Model, and specific educational requirements for licensure vary from state to state.18 The scope of practice for EMRs focuses on basic airway maneuvers such as head tilt and chin lift, use of the oropharyngeal airway, bag mask ventilation, and supplemental oxygen therapy.18 They have training in vital sign assessment, including manual blood pressure measurement, and have training in basic management of medical conditions, including assisting a patient in the use of autoinjectors, manual CPR and AED use.18 Their trauma training includes manual stabilization of cervical spine and extremity injuries, control of bleeding, and eye irrigation.18
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EMTs have the basic scope of practice of EMRs, and they can also manage ingestions and burns, provide oral glucose, assist patients with home medications such as inhalers and autoinjectors, stabilize injuries, and use noninvasive devices to maintain an open airway and assist breathing.18 EMT training includes basic anatomy and physiology with instruction in BLS practices, including CPR and AED usage.18 EMTs can elicit basic histories and perform physical examinations, and they have basic airway training for upper airway obstruction management and bag mask ventilation.18 They receive education in basic trauma care including spinal immobilization and splint application, and they are also trained to assist with medication administration to awake and alert patients, including oral and autoinjector medications.18
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AEMTs have the EMT scope of practice with the addition of skills in advanced airway management, including the use of supraglottic and tracheal airways.18 They also have training in intravenous and intraosseous needle placement, as well as administration of parenteral and inhaled medications.18
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Paramedics have the scope of practice of AEMTs with the addition of several more advanced skills.18 Paramedics undergo a rigorous educational regimen, which includes instruction on advanced airway management with direct laryngoscopy, end-tidal carbon dioxide monitoring, nasogastric and orogastric tube placement, electrocardiogram (ECG) with 12-lead interpretation to determine the need for cardioversion and transcutaneous pacing, needle decompression and chest tube placement, and infusion of blood products.18 In response to appropriate rhythms they are able to manually defibrillate, perform vagal maneuvers, administer synchronized cardioversion, and conduct transcutaneous pacing.18 For orthopedic injuries, they can straighten select fractures and reduce dislocations.18
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In 2009, the National Association of EMS Educators (NAEMSE) created the National EMS Education Standards in an effort to define minimal educational competencies for each level of EMS personnel as identified in the National EMS Scope of Practice Model.20 The education standards define the curriculum for teaching EMS students.20 Because there is no national school where EMS providers receive training, there is significant variation in training between states and between localities within states.20
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Each state maintains their own educational requirements for initial education and continuing education for providers to be certified in that state.19 All 50 states require that their EMS providers be licensed, and many require that EMS providers meet certification and recertification requirements delineated by the National Registry of Emergency Medical Technicians (NREMT).19 In most states, licensure renewal occurs every 2 to 3 years with continuing education often required for renewal.19 The NREMT has created specific guidelines outlining education requirements and proof of procedural skill competencies. An estimated 84% of the nation's EMTs are currently certified by the NREMT.19
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Rural EMS providers face many challenges when caring for children. They have longer transport times and care for fewer children in general, often resulting in challenges with pediatric specific skills retention.15 It is challenging to obtain training locally; thus, paramedic level providers are limited.20,21 Rural providers typically do not have standardized protocols available to them for care, and long transports with limited radio contact for online medical control often leaves them without guidance to provide care.21 When available, the medical direction for rural EMS providers often comes from local community hospitals where there is a lack of pediatric emergency medicine expertise.21 Moreover, there is a high turnover of EMS staff and a significant number of volunteer providers in these setting with little to no support for provision of continuing education.15 Finally, most programs must rely on grants to fund rural EMS programs as no systematic method exists to fund these programs.15