needed. Some who work for hospital trauma centers, which use helicopters to transport critically ill or injured patients, are part of the flight crew.

At the medical facility, EMTs and paramedics help transfer patients to the emergency department, report their observations and actions to staff, and may provide additional emergency treatment. Some paramedics are trained to treat patients with minor injuries on the scene of an accident or at their home without transporting them to a medical facility. After each run, EMTs replace used supplies and check equipment. If a transported patient had a contagious disease, EMTs decontaminate the interior of the ambulance and report cases to the proper authorities.

Beyond these general duties, the specific responsibilities of EMTs and paramedics depend on their level of qualification and training. To determine this, the National Registry of Emergency Medical Technicians (NREMT) registers emergency medical service (EMS) providers at four levels: First Responder, EMT-Basic, EMT-Intermediate, and EMT-Paramedic. Some States, however, do their own certification and use numeric ratings from 1 to 4 to distinguish levels of proficiency.

The lowest level-First Responders-are trained to provide basic emergency medical care because they tend to be the first persons to arrive at the scene of an incident. Many firefighters, police officers, and other emergency workers have this level of training. The EMT-Basic, also known as EMT-1, represents the first component of the emergency medical technician system. An EMT-1 is trained to care for patients on accident scenes and on transport by ambulance to the hospital under medical direction. The EMT-1 has the emergency skills to assess a patient's condition and manage respiratory, cardiac, and trauma emergencies.

The EMT-Intermediate (EMT-2 and EMT-3) has more advanced training that allows administration of intravenous fluids, use of manual defibrillators to give lifesaving shocks to a stopped heart, and use of advanced airway techniques and equipment to assist patients experiencing respiratory emergencies. EMT-Paramedics (EMT-4) provide the most extensive pre-hospital care. In addition to the procedures already described, paramedics may administer drugs orally and intravenously, interpret electrocardiograms (EKGs), perform endotracheal intubations, and use monitors and other complex equipment.

Working Conditions

EMTs and paramedics work both indoors and outdoors, in all types of weather. They are required to do considerable kneeling, bending, and heavy lifting. These workers risk noise-induced hearing loss from sirens and back injuries from lifting patients. In addition, EMTs and paramedics may be exposed to diseases such as Hepati

EMTS are often the first to appear at the scene of injuries.

tis-B and AIDS, as well as violence from drug overdose victims or psychologically disturbed patients. The work is not only physically strenuous, but also stressful, involving life-or-death situations and suffering patients. Nonetheless, many people find the work exciting and challenging and enjoy the opportunity to help others.

EMTs and paramedics employed by fire departments work about 50 hours a week. Those employed by hospitals frequently work between 45 and 60 hours a week, and those in private ambulance services, between 45 and 50 hours. Some of these workers, especially those in police and fire departments, are on call for extended periods. Because emergency services function 24 hours a day, EMTs and paramedics have irregular working hours that add to job stress.

Employment

EMTS and paramedics held about 150,000 jobs in 1998. In addition, there are many more volunteer EMTs, especially in smaller cities, towns, and rural areas, who work for departments where they may respond to only a few calls for service per month. Most career EMTs and paramedics work in metropolitan areas.

EMTs and paramedics are employed in a number of industries. Nearly half work in local and suburban transportation for private ambulance firms that transport and treat individuals on an emergency or non-emergency basis. About a third of EMTs and paramedics work in local government for fire departments and third service providers, in which emergency medical services are provided by an independent agency. Another fifth are found in hospitals, where they may work full-time within the medical facility or respond to calls in ambulances or helicopters to transport critically ill or injured patients.

Training, Other Qualifications, and Advancement

Formal training and certification is needed to become an EMT or paramedic. All 50 States possess a certification procedure. In 38 States and the District of Columbia, registration with the National Registry is required at some or all levels of certification. Other States administer their own certification examination or provide the option of taking the National Registry examination. To maintain certification, EMTs and paramedics must re-register, usually every 2 years. In order to re-register, an individual must be working as an EMT and meet a continuing education requirement.

Training is offered at progressive levels: EMT-Basic, also known as EMT-1; EMT-Intermediate, or EMT-2 and EMT-3; and EMT-paramedic, or EMT-4. The EMT-Basic represents the first level of skills required to work in the emergency medical system. Coursework typically emphasizes emergency skills such as managing respiratory, trauma, and cardiac emergencies and patient assessment. Formal courses are often combined with time in an emergency room or ambulance. The program also provides instruction and practice in dealing with bleeding, fractures, airway obstruction, cardiac arrest, and emergency childbirth. Students learn to use and maintain care for common emergency equipment, such as backboards, suction devices, splints, oxygen delivery systems, and stretchers. Graduates of approved EMT basic training programs who pass a written and practical examination administered by the State certifying agency or the National Registry of Emergency Medical Technicians earn the title of Registered EMT-Basic. The course is also a prerequisite for EMT-Intermediate and EMT-Paramedic training.

EMT-Intermediate training requirements vary from State to State. Applicants can opt to receive training in EMT-Shock Trauma, where the caregiver learns to start intravenous fluids and give certain medications, or in EMT-Cardiac, which includes learning heart rhythms and administering advanced medications. Training commonly includes 35-55 hours of additional instruction beyond EMT-Basic coursework and covers patient assessment as well as the use of advanced airway devices and intravenous fluids. Prerequisites for taking the EMT-Intermediate examination include registration as an

EMT-Basic, required classroom work, and a specified amount of clinical experience.

The most advanced level of training for this occupation is EMTParamedic. At this level, the caregiver receives additional training in body function and more advanced skills. The Paramedic Technology program usually lasts up to 2 years and results in an associate degree in applied science. Such education prepares the graduate to take the National Registry of Emergency Medical Technicians examination and become certified as an EMT-Paramedic. Extensive related coursework and clinical and field experience is required. Due to the longer training requirement, almost all EMT-Paramedics are in paid positions. Refresher courses and continuing education are available for EMTs and paramedics at all levels.

EMTs and paramedics should be emotionally stable, have good dexterity, agility, and physical coordination, and be able to lift and carry heavy loads. They also need good eyesight (corrective lenses may be used) with accurate color vision.

Advancement beyond the EMT-Paramedic level usually means leaving fieldwork. An EMT-Paramedic can become a supervisor, operations manager, administrative director, or executive director of emergency services. Some EMTs and paramedics become instructors, dispatchers, or physician assistants, while others move into sales or marketing of emergency medical equipment. A number of people become EMTs and paramedics to assess their interest in health care and then decide to return to school and become registered nurses, physicians, or other health workers.

Job Outlook

Employment of EMTs is expected to grow much faster than the average for all occupations through 2008. Much of this growth will occur as positions change from volunteer to paid and as the population grows, particularly older age groups that are the greatest users of emergency medical services. In addition to job growth, openings will occur because of replacement needs; some workers leave because of stressful working conditions, limited advancement potential, and the modest pay and benefits in the private sector.

Most opportunities for EMTs and paremedics are expected to arise in hospitals and private ambulance services. Competition will be greater for jobs in local government, including fire, police, and third service rescue squad departments, where job growth for these workers is expected to be slower.

Earnings

Earnings of EMTs depend on the employment setting and geographic location as well as the individual's training and experience. Median annual earnings of EMTs were $20,290 in 1998. The middle 50 percent earned between $15,660 and $26,240. The lowest 10 percent earned less than $12,700 and the highest 10 percent earned more than $34,480. In local and suburban transportation, where private ambulance firms are located, the median salary was $18,300 in 1997. In local government, except education and hospitals, the median salary was $21,900. In hospitals, the median salary was $19,900.

Those in emergency medical services who are part of fire or police departments receive the same benefits as firefighters or police officers. For example, many are covered by pension plans that provide retirement at half pay after 20 or 25 years of service or if disabled in the line of duty.

Related Occupations

Other workers in occupations that require quick and level-headed reactions to life-or-death situations are police officers, firefighters, air traffic controllers, and workers in other health occupations.

Sources of Additional Information

General information about EMTs and paramedics is available from: ☛ National Association of Emergency Medical Technicians, 408 Monroe St., Clinton, MS 39056. Internet: http://www.naemt.org

National Registry of Emergency Medical Technicians, P.O. Box 29233, Columbus, OH 43229. Internet: http://www.nremt.org

National Highway Transportation Safety Administration, EMS Divion, 400 7th St. SW., NTS-14, Washington DC. Internet: http://www.nhtsa.dot.gov/people/injury/ems/

Health Information Technicians (O*NET 32911)

Significant Points

Health information technicians are projected to be one of the 20 fastest growing occupations.

High school students can improve chances of acceptance into a health information education program by taking courses in biology, chemistry, health, and especially computer training.

Most technicians will be employed by hospitals, but job growth will be faster in offices and clinics of physicians, nursing homes, and home health agencies.

Nature of the Work

Every time health care personnel treat a patient, they record what they observed, and how the patient was treated medically. This record includes information the patient provides concerning their symptoms and medical history, the results of examinations, reports of x-rays and laboratory tests, diagnoses, and treatment plans. Health information technicians organize and evaluate these records for completeness and accuracy.

Health information technicians, who may also be called medical record technicians, begin to assemble patients' health information by first making sure their initial medical charts are complete. They ensure all forms are completed and properly identified and signed, and all necessary information is in the computer. Sometimes, they talk to physicians or others to clarify diagnoses or get additional information.

Technicians assign a code to each diagnosis and procedure. They consult classification manuals and rely, also, on their knowledge of disease processes. Technicians then use a software program to assign the patient to one of several hundred "diagnosis-related groups," or DRG's. The DRG determines the amount the hospital will be reimbursed if the patient is covered by Medicare or other insurance programs using the DRG system. Technicians who specialize in coding are called health information coders, medical record coders, coder/abstractors, or coding specialists. In addition to the DRG system, coders use other coding systems, such as those geared towards ambulatory settings.

Technicians also use computer programs to tabulate and analyze data to help improve patient care or control costs, for use in legal actions, or in response to surveys. Tumor registrars compile and maintain records of patients who have cancer to provide information to physicians and for research studies.

Health information technicians' duties vary with the size of the facility. In large to medium facilities, technicians may specialize in one aspect of health information, or supervise health information clerks and transcribers while a health information administrator manages the department (see the statement on health services managers elsewhere in the Handbook). In small facilities, an accredited health information technician sometimes manages the department.

Working Conditions

Health information technicians usually work a 40-hour week. Some overtime may be required. In hospitals where health information departments are open 18-24 hours a day, 7 days a week, they may work day, evening, and night shifts.

Hospitals sometimes advance promising health information clerks to jobs as health information technicians, although this practice may be less common in the future. Advancement usually requires 2-4 years of job experience and completion of a hospital's in-house training program.

Most employers prefer to hire Accredited Record Technicians (ART), who must pass a written examination offered by AHIMA. To take the examination, a person must graduate from a 2-year associate degree program accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) of the American Medical Association. Technicians trained in non-CAAHEP accredited programs, or on the job, are not eligible to take the examination. In 1998, CAAHEP accredited 168 programs for health information technicians. Technicians who specialize in coding may also obtain voluntary certification.

Experienced health information technicians usually advance in one of two ways-by specializing or managing. Many senior health information technicians specialize in coding, particularly Medicare coding, or in tumor registry.

In large health information departments, experienced technicians may advance to section supervisor, overseeing the work of the coding, correspondence, or discharge sections, for example. Senior technicians with ART credentials may become director or assistant director of a health information department in a small facility. However, in larger institutions, the director is a health information administrator, with a bachelor's degree in health information administration. (See the statement on health services managers elsewhere in the Handbook.)

Job Outlook

Job prospects for formally trained technicians should be very good. Employment of health information technicians is expected to grow much faster than the average for all occupations through 2008, due to rapid growth in the number of medical tests, treatments, and procedures which will be increasingly scrutinized by third-party payers, regulators, courts, and consumers.

Hospitals will continue to employ a large percentage of health information technicians, but growth will not be as fast as in other areas. Increasing demand for detailed records in offices and clinics of physicians should result in fast employment growth, especially in large group practices. Rapid growth is also expected in nursing homes and home health agencies.

Sources of Additional Information

Information on careers in health information technology, including a list of CAAHEP-accredited programs is available from:

☛ American Health Information Management Association, 233 N. Michigan Ave., Suite 2150, Chicago, IL 60601. Internet: http://www.ahima.org

Licensed Practical Nurses

(O*NET 32505)

Significant Points

Training lasting about 1 year is available in about 1,100 State-approved programs, mostly in vocational or technical schools.

• Nursing homes will offer the most new jobs. Jobseekers in hospitals may face competition.

Nature of the Work

Licensed practical nurses (L.P.N.s), or licensed vocational nurses as they are called in Texas and California, care for the sick, injured, convalescent, and disabled under the direction of physicians and registered nurses. (The work of registered nurses is described elsewhere in the Handbook.)

Most L.P.N.s provide basic bedside care. They take vital signs such as temperature, blood pressure, pulse, and respiration. They also treat bedsores, prepare and give injections and enemas, apply dressings, give alcohol rubs and massages, apply ice packs and hot water bottles, and insert catheters. L.P.N's observe patients and report adverse reactions to medications or treatments. They collect samples from patients for testing, perform routine laboratory tests, feed them, and record food and liquid intake and output. They help patients with bathing, dressing, and personal hygiene, keep them comfortable, and care for their emotional needs. In States where the law allows, they may administer prescribed medicines or start intravenous fluids. Some L.P.N.s help deliver, care for, and feed infants. Some experienced L.P.N.s supervise nursing assistants and aides.

L.P.N.s in nursing homes, in addition to providing routine bedside care, may also help evaluate residents' needs, develop care plans, and supervise the care provided by nursing aides. In doctors' offices and clinics, they may also make appointments, keep records, and perform other clerical duties. L.P.N.s who work in private homes may also prepare meals and teach family members simple nursing tasks.

Many licensed practical nurses work nights and weekends.

Working Conditions

Most licensed practical nurses in hospitals and nursing homes work a 40-hour week, but because patients need round-the-clock care, some work nights, weekends, and holidays. They often stand for long periods and help patients move in bed, stand, or walk.

L.P.N.s may face hazards from caustic chemicals, radiation, and infectious diseases such as hepatitis. They are subject to back injuries when moving patients and shock from electrical equipment. They often must deal with the stress of heavy workloads. In addition, the patients they care for may be confused, irrational, agitated, or uncooperative.

Employment

Licensed practical nurses held about 692,000 jobs in 1998. Thirtytwo percent of L.P.N.s worked in hospitals, 28 percent worked in nursing homes, and 14 percent in doctors' offices and clinics. Others worked for temporary help agencies, home health care services, residential care facilities, schools, or government agencies. About 1 in 4 worked part time.

Training, Other Qualifications, and Advancement

All States require L.P.N.s to pass a licensing examination after completing a State-approved practical nursing program. A high school diploma is usually required for entry, but some programs accept people without a diploma.

In 1998, approximately 1,100 State-approved programs provided practical nursing training. Almost 6 out of 10 students were enrolled in technical or vocational schools, while 3 out of 10 were in community and junior colleges. Others were in high schools, hospitals, and colleges and universities.

Most practical nursing programs last about 1 year and include both classroom study and supervised clinical practice (patient care). Classroom study covers basic nursing concepts and patient-care related subjects, including anatomy, physiology, medical-surgical nursing, pediatrics, obstetrics, psychiatric nursing, administration of drugs, nutrition, and first aid. Clinical practice is usually in a hospital, but sometimes includes other settings.

L.P.N.s should have a caring, sympathetic nature. They should be emotionally stable because work with the sick and injured can be stressful. As part of a health care team, they must be able to follow orders and work under close supervision.

Job Outlook

Employment of L.P.N.s is expected to grow as fast as the average for all occupations through 2008 in response to the long-term care needs of a rapidly growing population of very old people and to the general growth of health care. However, L.P.N.s seeking positions in hospitals may face competition, as the number of hospital jobs for L.P.N.s declines; the number of inpatients, with whom most L.P.N.s work, is not expected to increase much. As in most other occupations, replacement needs will be a major source of job openings.

Employment in nursing homes is expected to grow faster than the average. Nursing homes will offer the most new jobs for L.P.N.S as the number of aged and disabled persons in need of long-term care rises. In addition to caring for the aged, nursing homes will be called on to care for the increasing number of patients who have been released from the hospital and have not recovered enough to return home.

Much faster than average growth is expected in home health care services. This is in response to a growing number of older persons with functional disabilities, consumer preference for care in the home, and technological advances, which make it possible to bring increasingly complex treatments into the home.

An increasing proportion of sophisticated procedures, which once were performed only in hospitals, are being performed in

L.P.N.s work closely with people while helping them. So do emergency medical technicians, social and human service assistants, surgical technologists, and teacher assistants.

Sources of Additional Information

For information about practical nursing, contact:

National League for Nursing, 61 Broadway, New York, NY 10006. Internet: http://www.nln.org

National Association for Practical Nurse Education and Service, Inc., 1400 Spring St., Suite 330, Silver Spring, MD 20910.

Nuclear Medicine Technologists

(O*NET 32914)

Significant Points

• Relatively few job openings will occur because the occupation is small.

Technologists trained in both nuclear medicine and radiologic technology or other modalities will have the best prospects.

Nature of the Work

In nuclear medicine, radionuclides-unstable atoms that emit radiation spontaneously-are used to diagnose and treat disease. Radionuclides are purified and compounded like other drugs to form radiopharmaceuticals. Nuclear medicine technologists administer these radiopharmaceuticals to patients, then monitor the characteristics and functions of tissues or organs in which they localize. Abnormal areas show higher or lower concentrations of radioactivity than normal.

Nuclear medicine technologists operate cameras that detect and map the radioactive drug in the patient's body to create an image on photographic film or a computer monitor. Radiologic technologists also operate diagnostic imaging equipment, but their equipment creates an image by projecting an x ray through the patient. (See the statement on radiologic technologists elsewhere in the Handbook.)

Nuclear medicine technologists explain test procedures to patients. They prepare a dosage of the radiopharmaceutical and administer it by mouth, injection, or other means. When preparing radiopharmaceuticals, technologists adhere to safety standards that keep the radiation dose to workers and patients as low as possible. Technologists position patients and start a gamma scintillation camera, or "scanner," which creates images of the distribution of a

A nuclear medicine technologist prepares equipment for a full-body scan of a patient.

radiopharmaceutical as it localizes in and emits signals from the patient's body. Technologists produce the images on a computer screen or on film for a physician to interpret. Some nuclear medicine studies, such as cardiac function studies, are processed with the aid of a computer.

Nuclear medicine technologists also perform radioimmunoassay studies that assess the behavior of a radioactive substance inside the body. For example, technologists may add radioactive substances to blood or serum to determine levels of hormones or therapeutic drug content.

Technologists keep patient records and record the amount and type of radionuclides received, used, and disposed of.

Working Conditions

Nuclear medicine technologists generally work a 40-hour week. This may include evening or weekend hours in departments that operate on an extended schedule. Opportunities for part-time and shift work are also available. In addition, technologists in hospitals may have on-call duty on a rotational basis.

Because technologists are on their feet much of the day, and may lift or turn disabled patients, physical stamina is important.

Although there is potential for radiation exposure in this field, it is kept to a minimum by the use of shielded syringes, gloves, and other protective devices and adherence to strict radiation safety guidelines. Technologists also wear badges that measure radiation levels. Because of safety programs, however, badge measurements rarely exceed established safety levels.

Employment

Nuclear medicine technologists held about 14,000 jobs in 1998. About 8 out of 10 jobs were in hospitals. The rest were in physicians' offices and clinics, including imaging centers.

Training, Other Qualifications, and Advancement Nuclear medicine technology programs range in length from 1 to 4 years and lead to a certificate, associate's degree, or bachelor's degree. Generally, certificate programs are offered in hospitals, associate programs in community colleges, and bachelor's programs in 4-year colleges and in universities. Courses cover physical sciences, the biological effects of radiation exposure, radiation protection and procedures, the use of radiopharmaceuticals, imaging techniques, and computer applications.

One-year certificate programs are for health professionals, especially radiologic technologists and ultrasound technologists, who wish to specialize in nuclear medicine. They also attract medical