Operations Study Guide for the EMT Test

Medical, Legal, and Ethical Issues

Providing EMS involves understanding and applying many medical, legal, and ethical issues. EMTs need to understand consent, patient autonomy, legal obligations, and ethics.

EMS Operations Information

Before we go into other specific legal, moral, and ethical issues, let’s review the background information you should know. Your role in EMS operations will make more sense once you can see the entire picture.

Four Training and Licensure Levels

Most states typically follow national guidelines developed by the National Highway Traffic Safety Administration (NHTSA) in the National EMS Scope of Practice Model. The latest model went into effect in 2005 and made changes to the levels of certification and skills practiced.

Emergency Medical Responder

EMRs have very basic training and provide care prior to the arrival of EMTs. Training includes familiarity with some EMT procedures and equipment but not competency in those procedures or in ambulance operations.

Emergency Medical Technician

EMTs are trained to provide basic life support (BLS) to ill and injured patients. This training includes the use of airway adjuncts, automated external defibrillation, and assisting patients with certain medications. EMT training is the foundation for the next levels of certification, and EMTs are often considered the backbone of EMS systems. Training is typically 150 hours, depending on the state. This is what you are training for.

Advanced Emergency Medical Technician

AEMT builds on the EMT training to include limited advanced life support (ALS) care such as IV therapy, use of advanced airway adjuncts, and the administration of certain emergency medications. Training is typically 200-400 hours.

Paramedic

Paramedic is the highest level of pre-hospital training. It includes comprehensive training in basic and advanced life support knowledge and skills, including endotracheal intubation, emergency pharmacology, and cardiac monitoring. Training ranges from 1,000 to 1,300 hours, and it is becoming common for it to be included as part of a college degree.

Here are some concepts to know:

Advanced Life Support (ALS)—This is the level of emergency care that goes beyond basic life support to include advanced airway management, cardiac monitoring, intravenous therapy, medication administration, and other specialized interventions. ALS is typically provided by paramedics or other highly trained personnel to stabilize critically ill or injured patients before or during transport to a hospital.
Automated External Defibrillator (AED)—portable electronic device that automatically analyzes a patient’s heart rhythm and, if needed, delivers an electric shock to restore a normal heart rhythm in case of sudden cardiac arrest
Emergency Medical Responder (EMR)—the first trained professional or responder to arrive at the scene of a medical emergency; provides basic life support, patient assessment, and immediate care until higher-level care arrives
Emergency Medical Technician (EMT)—trained EMS professional who provides basic emergency medical care and transportation for patients who are ill or injured; can perform patient assessment, CPR, basic airway management, oxygen administration, bleeding control, and limited medication administration
Advanced EMT (AEMT)—EMS provider trained to provide basic and limited advanced life support; in addition to EMT skills, can administer certain medications, start IVs, and perform advanced airway management
Paramedic—highly trained professional who provides advanced life support care in the prehospital setting; in addition to EMT and AEMT skills, can perform advanced airway management, interpret ECGs, administer a wide range of medications, perform invasive procedures, and make complex patient care decisions

History of EMS

In the past, civilian EMS was not organized and varied widely by location. It was commonly provided by funeral homes, with minimal care beyond the ability to transport someone on a stretcher. A few urban areas had better equipped ambulance services, but the focus was still on transport. Modern EMS systems are considered to have had their start with the passage of federal legislation in the 1960s and ’70s that provided guidance and funding for development.

Here are some concepts to know:

The White Paper—formally titled “Accidental Death and Disability”; a report published in 1966 that highlights the high number of preventable deaths from trauma and medical emergencies in the United States, leading to the creation and development of the modern EMS system
National Highway Transportation Safety Administration (NHTSA)—federal agency within the US Department of Transportation that works to reduce deaths, injuries, and economic losses from motor vehicle crashes by the development of national standards, guidelines, and educational materials for use by prehospital emergency medical services
Highway Safety Act of 1966—federal law that established national standards for highway and traffic safety and led to the creation of coordinated state highway safety programs
EMS Agenda for the Future—national blueprint developed by the National Highway Traffic Safety Administration that outlines a long-term vision for the evolution of EMS in the United States

Important Components of the EMS System

The EMS Agenda for the Future defines 14 components of EMS systems that interact with each other. An EMS system cannot function without all of them, and it is important to understand and know each of them.

Public Access

A system to request help is vital. In most areas, this is provided by dialing 9-1-1 and being connected to an emergency communication center. Dispatchers can assess information, send ambulances and other responders, and provide first aid and CPR instructions.

Communication Systems

Radio and other communication links are essential for sending resources. GPS can be used to track the locations of responders. Wireless communications can be used to transmit important information such as response maps and updated information to computers in the ambulance.

Clinical Care

EMTs are trained to use a variety of emergency equipment. Clinical care describes the various pieces of equipment and when the equipment is indicated or contraindicated for use. Also, familiarity with the primary service area, checking equipment, and being able to operate all the features in the ambulance are necessary.

Human Resources

How people are recruited, compensated, and retained are important functions of human resources. The goal is to create systems that attract and retain talented people. Interstate mobility, career ladders, and protection of employee well-being are vital to achieving these goals.

Medical Direction

Each EMS system has a set of protocols written by a physician who authorizes the care provided by EMTs. These protocols constitute the EMT’s scope of practice. Modifications or further treatments may be directed by online medical control. Training and continuing education requirements are also determined by the medical director.

Legislation and Regulation

EMS systems are governed by individual state laws and regulations. State EMS offices administer these laws and provide oversight, often with input from an advisory committee. Locally, EMS systems have individual policies and procedures regarding daily operations.

Integration of Health Services

EMS care is only the start of the patient’s medical journey. The care started must be integrated with the receiving hospitals to assure proper coordination. Many EMS systems have developed special alert procedures for certain time-sensitive conditions, such as stroke and heart attacks.

Evaluation

Continuous quality improvement is a circular process of reviewing and improving the processes of patient care and reducing error. Errors can be rule, knowledge, or skill-based and are inevitable in systems run by humans. EMTs have an obligation to recognize and reduce errors.

Information Systems

Computer technology has become an integral part of EMS systems. Data can be used for a wide variety of purposes, including staffing, equipment justification, and identifying training needs. Federal data reporting provides a snapshot of EMS that can be used to improve planning.

System Finance

Regardless of the type of EMS system, funding is needed for continued operations. Funding may come from many sources, including patient fees, taxes, donations, and grants. EMTs play a critical role by properly documenting care and obtaining patient billing signatures.

Education Systems

Education systems are critical for producing EMS providers and offering continuing education. Accreditation is common, and some states require special certification for EMS educators. EMTs have a professional duty to maintain knowledge and obtain the required continuing education hours.

Prevention

EMS can be considered part of the public health system. The goal of public health is to prevent health problems, which can then reduce the costs of healthcare. EMTs’ knowledge about the causes of injury and illness in their community can be used for prevention efforts.

Public Education

EMTs can play important roles in educating the public about healthy behaviors and injury prevention. CPR and first aid education of the public can minimize the effects of events when they occur. Public education efforts also increase the standing of EMTs in the community.

Research

EMS treatments were often adopted from other healthcare providers. Evidence-based medicine is now being used to guide EMS treatment. Good documentation may be vital to gathering research information. Research must be read carefully to understand the results.

Here are some concepts to know:

public safety answering point—This is the 9-1-1 call center where emergency calls are first received. Trained telecommunicators at the public safety answering point (PSAP) gather essential information from the caller, determine the type and location of the emergency, and dispatch the appropriate emergency services such as EMS, fire, or police.
emergency medical dispatch (EMD)—a system in which trained dispatchers receive emergency calls, gather critical information, prioritize the call, and provide pre-arrival instructions to callers while EMS units are being sent to the scene
primary service area (PSA)—geographic region that an EMS agency is officially responsible for covering and responding to emergency calls within
medical director—licensed physician who provides medical oversight for an EMS system, including developing protocols, authorizing medical procedures and medications, and ensuring the quality and medical appropriateness of patient care provided by EMS personnel
medical control—supervision and direction of EMS personnel by a physician or designated authority to ensure appropriate patient care, either through direct communication or written protocols and standing orders
mobile integrated healthcare (MIH)—patient-centered model of care in which EMS providers deliver healthcare services outside of traditional emergency response, such as follow-up care, chronic disease management, and referrals, in coordination with other healthcare professionals to reduce unnecessary emergency department visits
continuous quality improvement (CQI)—an ongoing process used in EMS to review performance, identify areas for improvement, and implement changes to enhance the quality, safety, and effectiveness of patient care
National EMS Information System (NEMSIS)—nationwide database that collects standardized information from EMS patient care reports to improve EMS operations, research, education, and patient outcomes
public health—the science and practice of protecting and improving the health of communities through disease prevention, health education, policy-making, and promotion of a healthy lifestyle
primary prevention—actions taken to prevent a disease, injury, or condition before it occurs (immunizations, education, safety measures)
secondary prevention—early detection and intervention to stop or slow the progression of a disease or injury (screening tests, checkups, prompt treatment)

Roles of the EMT

EMTs have many roles and responsibilities, from knowing their equipment to protecting patient privacy under HIPAA. EMTs must also display professional attributes, including appearance, integrity, empathy, and respect.

Here is a concept to know:

Health Insurance and Portability and Accountability Act (HIPAA)—federal law that protects the privacy and security of a patient’s medical information, ensures the confidentiality of health records, and sets standards for the handling and sharing of personal health information by providers and organizations

Public and EMT Education and Training

As a public servant, the EMT should ensure that CPR skills stay fresh. Use the many resources available to stay up to date and remain confident about these skills. Public education is also important as timing in these critical situations can enhance survival rates. Become active in the community education process in your jurisdiction and/or community.

Here is a concept to know:

resources for CPR updates and community classes—includes the American Heart Association (AHA) website heart.org, which provides public classes as well as lists their widely accepted CPR guidelines; the American Red Cross; National Safety Council; American Health & Safety Institute; and National Academy/EMS World; all of which provide valuable research, resources, and information

Consent is required from all patients and competent patients have the right to refuse care. Expressed consent from the patient is ideal, but special circumstances such as implied consent when a patient is unconscious or when dealing with minors are common. Involuntary consent may involve forcible restraint on a person who is mentally incapable of providing expressed consent.

Here are some terms and concepts to know:

consent—permission given by a patient to receive medical care
decision-making capacity—patient’s ability to understand the information about their medical condition and treatment options, appreciate the consequences, and make an informed choice regarding their care
patient autonomy—principle that a patient has the right to make their own decisions based on their values, beliefs, and preferences, even if those decisions differ from the recommendations of healthcare providers
expressed consent—when a patient clearly and verbally or through gesture agrees to receive medical care or treatment
informed consent—when a patient voluntarily agrees to a treatment or procedure after being given clear information about the risks, benefits, and alternatives, and demonstrates understanding of that information
implied consent—when a patient is unable to give verbal or written permission (they are unconscious, confused, or in danger) and it is assumed that they would consent to emergency medical care
emergency doctrine—legal principle that allows healthcare providers to give immediate care without consent when a patient is unable to provide consent and delaying treatment would result in serious harm or death
medicolegal—legal aspects of medical practice, including laws, regulations, and ethical considerations, that affect patient care and the actions of healthcare providers
emancipated minor—person under the legal age of adulthood who is legally recognized as independent and able to make their own medical decisions without parental consent
in loco parentis—legal term meaning “in place of parents”, refers to an adult who has been given the authority to make decisions for a minor when a parent or legal guardian is not present
forcible restraint—physical or mechanical restriction of a patient’s movement used only when necessary to prevent the patient from harming themselves or others, and when less restrictive measures have failed

Patient Rights

Patients have a right to confidentiality of medical care. HIPAA protects, by law, a patient’s protected health information from disclosure. Advanced directives specify a patient’s healthcare wishes when they are no longer able to do so themselves. These include such documents as a living will or a DNR order.

Physical Signs of Death

Physical signs of death can be categorized as presumptive and definitive signs. Except in special circumstances, resuscitation should be withheld from patients with definitive signs of death. A medical examiner will often become involved in cases of death outside of a hospital.

Here are some concepts to know:

presumptive signs—indirect indicators that suggest a medical condition or injury may be present but do not confirm it, such as a patient’s complaints, history, or observed symptoms
definitive signs—clear, objective findings that confirm the presence of a specific medical condition or injury, such as visible fractures, abnormal diagnostic test results, or positive clinical findings
dependent lividity—purplish discoloration of the skin that occurs after death as blood settles in the lowest parts of the body due to gravity, indicating that circulation has stopped
rigor mortis—stiffening of the muscles after death due to chemical changes in the muscle tissue, typically beginning 2 to 6 hours postmortem and fully developing by 12 hours, then gradually dissipating after 48 to 60 hours
putrefaction—decomposition of body tissue after death

Special Situations

Some patients may have consented to organ donation. In some areas, donation of organs or tissue can still occur after death, and EMTs should be familiar with practices in their area. Patients may have medical ID-type bracelets with important medical information.

Giving Care

EMTs must operate within their scope of practice. Standards of care are determined by laws, institutional standards, published textbooks, and professional organizations. Duty to act is an EMT’s obligation to provide patient care and is defined by law and departmental policy.

Here are some concepts to know:

standard of care—level of care and skill that a reasonably competent healthcare provider, with similar training and experience, would provide under similar circumstances
emergency—situation in which a person’s life, health, or safety is at immediate risk and requires urgent medical attention or intervention
**duty to act **—legal obligation of an EMT or healthcare provider to provide care to a patient once they have been called to respond or are on duty
**Medical Orders for Life-Sustaining Treatment (MOLST) **—a medical order that communicates a patient’s wishes regarding life-sustaining treatments, such as CPR, intubation, and other resuscitative measures

Extreme Situations

Failure to conform to accepted standards of care or outside of the EMT’s scope of practice is negligence. Patient care must be continued until transferred to another provider and care cannot be forced on competent patients. Inappropriate or false disclosure can result in defamation.

Here are some concepts to know:

negligence—failure to provide the standard of care that a reasonably prudent person or healthcare provider would under similar circumstances, resulting in harm or injury to a patient
proximate causation—direct link between a healthcare provider’s actions (or inactions) and a patient’s injury or harm, showing that the injury was a foreseeable result of the provider’s breach of the standard of care
res ipsa loquitur—legal doctrine meaning “the thing speaks for itself”, used in negligence cases when the injury clearly would not have occurred without someone’s negligence, even if direct evidence of the negligent act is lacking
negligence per se—occurs when a healthcare provider violates a law or regulation that is designed to protect the public, and that violation directly causes harm to a patient, automatically establishing negligence without needing to prove a breach of the standard of care
torts—civil wrongs, other than breaches of contract, in which a person’s actions (or failure to act) cause harm or injury to another, potentially resulting in legal liability
abandonment—unilateral termination of patient care by an EMS provider without the patient’s consent and without ensuring that equal or higher-level care is continued, which can result in harm to the patient
assault—act of intentionally threatening or attempting to cause physical harm to another person, creating a reasonable fear of imminent injury, even if no physical contact occurs
battery—intentional and unauthorized physical contact with a patient, such as providing medical treatment without consent
kidnapping—unlawful restraint, movement, or transportation of a person without their consent, such as transporting a patient against their will when they have decision-making capacity
false imprisonment—unlawful restriction of a person’s freedom of movement without legal authority or consent, such as preventing a patient with decision-making capacity from leaving the scene
defamation—false communication of information about a person that damages their reputation, can be slander (spoken) or libel (written)
libel—written defamation
slander—spoken defamation

Good Samaritan Laws

All states have passed Good Samaritan laws that provide at least some degree of legal protection to EMS providers who render aid within the scope of their training. Some states also have expanded EMS laws to provide immunity except in cases of gross negligence or willful misconduct.

Here are some concepts to know:

Good Samaritan laws—statutes that protect individuals who provide emergency care in good faith from legal liability, as long as they act within the scope of practice of their training and do not exhibit gross negligence or willful misconduct
gross negligence—severe departure from the standard of care, showing reckless disregard for the safety or life of a patient, beyond ordinary negligence
immunity—legal protection from civil liability granted to individuals or organizations, allowing them to perform certain duties, such as providing emergency medical care, without being held legally responsible, as long as they act within the law and scope of practice

Legal Considerations

Accurate written records should be maintained about all patient contacts for possible future court appearances or legal proceedings. Reporting cases of abuse or neglect is typically required by EMTs. All patient care should be conducted in an ethical manner.

Here are some concepts to know:

mandated reporting—legal requirement for EMS providers and other healthcare professionals to report suspected abuse, neglect, or exploration (child abuse, elder abuse, injuries) to the appropriate authorities
ethics—study and practice of moral principles that guide a person’s behavior, helping healthcare providers determine what is right and wrong in patient care and professional conduct
morality—person’s beliefs and values about right and wrong behavior, which guide individual choices and actions, including decisions in healthcare and daily life
bioethics—study of ethical issues in medicine and healthcare, focusing on questions about patient rights, medical treatments, life and death decisions, and responsibilities of healthcare providers
applied ethics—practical use of ethical principles to guide real-world decision-making, especially in fields like healthcare, law, and business, to resolve moral dilemmas and determine the right course of action
statute of limitations—legal time limit within which a person can file a lawsuit or legal claim, after which the right to take legal action is generally lost
governmental immunity—legal protection that shields government agencies and their employees from being sued for actions performed within the scope of their official duties
discovery—pre-trial process in a legal case in which both parties gather and exchange information, evidence, and documents to prepare for trial
deposition—sworn, out-of-court testimony given by a witness or party in a legal case, recorded for use in court
compensatory damages—monetary awards given to a plaintiff in a lawsuit to reimburse actual losses or injuries suffered, such as medical expenses, lost wages, or pain and suffering
punitive damages—monetary awards intended to punish a defendant for particularly reckless, malicious, or egregious behavior and to deter similar conduct in the future