Paramedics in the United States
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A paramedic, is a highly trained medical professional who responds to and treats all types of medical and trauma emergencies outside of a hospital setting before and during transportation to an appropriate medical facility. Paramedics also work in the inter-facility transport environment where a paramedic will continue or upgrade medical care to a higher level while transporting a patient from one healthcare facility to another. Paramedics usually transport patients to a hospital based emergency department, but paramedics can treat patients out of the hospital setting and then not transport the patient to the hospital (i.e. a paramedic gives a diabetic patient 50% dextrose in water). Paramedics derive the legal ability to provide advanced life support care through a medical doctor's license. In many ways, a paramedic is an extension to the services offered by a medical doctor.
In the United States, emergency medical technicians (EMT) are classified according to their level of license/certification. Nationally, EMTs are classified as EMT-Paramedic, EMT-Intermediate, EMT-Basic, and First Responders. The paramedic is the most advanced EMT. Some states designate other levels of certification/licensure such as EMT-Advanced, EMT-Shock Trauma, etc. Some states refer to individuals that are educated and trained at the EMT-Intermediate level as EMT-Cardiac, EMT-Cardiac Rescue Technician, etc.
In the United States, the Department of Transportation designs and specifies a National Standard Curriculum for the EMT-Basic, EMT-Intermediate, and EMT-Paramedic. Most paramedic education programs and most certifying agencies (i.e. states) require that a student is at a minimum educated and trained to the National Standard Curriculum for a particular skill level. US DOT National Standard Curriculum for EMT - First Responder/Basic/Intermediate/Paramedic
The National Registry of Emergency Medical Technicians is a private, central certifying entity whose main purpose is to maintain a national standard and assist in the ability of paramedics to perform their job functions should they relocate from the state in which they gained certification. Individual states set their own standards of certification, often based on or identical to, the National Registry. The National Registry of Emergency Medical Technicians recognizes three levels of EMT: EMT-B (Basic), EMT-I (Intermediate) and EMT-P (Paramedic).
In the field, the levels of training are separated into BLS (Basic Life Support), ILS (Intermediate Life Support) and ALS (Advanced Life Support) units. In addition to the basic-level skills CPR, first aid, airway management, oxygen administration, spinal immobilization, traction splinting, bleeding control and splinting, as well as the intermediate skills of IV therapy, endotracheal intubation and initial cardiac drug therapy, the paramedic is also educated in EKG interpretation, advanced respiratory support and airway skills including RSI, pharmacology, trauma resuscitation, pediatric life support and advanced cardiac life support. Some U.S. states, and the National Registry, require ongoing continuing education and verification of clinical skills capability to maintain a paramedic certification. Other states have permanent certification, except for issues involving gross negligence and malpractice.
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[edit] Issues
Staffing: Much like the shortage of other health care professionals (nurses, radiology tech, respiratory therapists, PMD, etc.), there is also a shortage of paramedics in some areas. Over the last five years there has been an increase in the need for paramedics as more and more fire departments add paramedics cross-trained as firefighters to staff fire trucks (engines, squads/rescues, trucks, etc.). The educational requirements of the position (about two years of education and training) and generally low salary are pushing potential and current paramedics into other health care fields like nursing, medical assisting, medical doctor, etc. The paramedic profession requires the same time and educational commitment as nursing, but tends to pay significantly less and provide far fewer job options outside of an EMS system.
Lack of Professional Equality: Many health care systems tier paramedics as less skilled and less educated than nurses, despite this often being quite the opposite. Due to many factors, including call volume, extreme time constraints for treatment & transport (almost always occurring at the same time), and the lack of stable, sterile and safe environments that hospitals provide, the majority of paramedics are able to function and treat patients on a daily basis in situations that would test the abilities of many "In-Hospital" providers, including nurses and doctors. Paramedics are exceptional at "street medicine" and improvisational treatment methods, that mainly are developed from experience working in low or no-light, tight spaces, environmental dangers such as unseen bodily fluids, chemicals & drugs, and severe weather conditions. They are highly adept at assessing patients using their own instincts and senses, agumented by their education and experience, a skill that many in-hospital providers lack due to a reliance on the highly advanced (and expensive) technology and equipment. Many paramedics feel as though the general public - and other medical professionals - lack the respect or understanding of the capability and education of a paramedic. A large factor for this is political, as most health care systems are dominated by nurses unions and councils, who want to maintain their value, job options and pay rates, which would be threatened if paramedics were granted professional equality. Another factor for this is due to the fact that prior to 1970 there was no such thing as a paramedic (at least in modern terms). Due to the relative infancy of Paramedics as educated health care providers and not simple "ambulance drivers", they are often still seen as "clinicians" rather then true professionals. To still be viewed as an "ambulance driver" is a notion highly contested and usually offensive to paramedics. Currently, the only options available for a paramedic to "further" their career is to pursue a nursing or doctorate degree, become an instructor, or government-level disaster management degrees/positions (such a local or federal disaster agencies like FEMA). Fire Departments rarely provided a "career ladder" beyond lieutenant or captain within the department for paramedics unless they become cross trained as fire fighters.
Stress: The job duties of a Paramedic are some of the most stressful in the world. Since most paramedics meet a citizen during what may be the worst time of his or her or their family member's life, the general public can treat paramedics poorly. Paramedics must often treat both the patient's condition and the psychological states of bystanders/family members. Of all the factors, treating sick, injured or dead children are ranked highest amongst paramedics as the most stressful part of the job. This is all coupled with the daily human suffering to which a paramedic must be witness. Many paramedics often find themselves caught in dangerous or violent situations with either their patients or bystanders, and often without police back-up. In some dense urban EMS systems, Paramedics and EMTs are issued ballistic vests such a Kevlar. Additionaly, the unstable environment paramedics work in put them in high-risk situations for contracting blood-born pathogens such as Hepatitis C, HIV/AIDS and tuberculosis, which can be transmitted from accidental needle punctures, blood sprays and coughing/spitting. All of these factors contribute to what's called the "burn-out rate", or life span of their career, which is one of the highest of any profession. The average field time of a paramedic is said to be around seven years before they move on. Some EMS systems, such as New York, Philadelphia and Los Angeles, the "burn-out rate" is even lower, sometimes 3 years or less.
Paramedics are employed by various public and private emergency service providers. These include private ambulance services, fire departments, and the 9-1-1 system, hospitals, law enforcement agencies, the military, or various EMS-specific, or "third service" public safety agencies. Paramedics may respond to medical incidents in an ambulance, rescue vehicle, helicopter, fixed-wing aircraft, motorcycle, and increasingly in a fire suppression apparatus.
As nursing shortages become more and more prevalent, paramedics are increasingly used in Emergency Departments and Intensive Care Units of hospitals. Often, paramedics operate with greater latitude and autonomy than many nurses. In addition, paramedics are often used as chief medical personnel on offshore drilling platforms and on MEDEVACs and airplanes. However, paramedics may be employed in many different medical fields that do not necessarily involve transportation of patients. Such positions may include phlebotomy, blood banks, research labs, and educational fields.
In the U.S., paramedic salaries can range anywhere from unpaid volunteer positions to as much as $90,000 a year, depending on location, experience, and supervisory responsibilities. It should be noted that volunteer paramedics can generally provide the same level of care as those performing the service in a career capacity, depending on the local scope of practice.
[edit] History
Prior to the 1970s, ambulances were staffed with advanced first-aid level responders who were frequently referred to as "ambulance drivers." There was little regulation or standardized training for those staffing these early emergency response vehicles. However, after the release of the National Academy of Science's "White Paper" on motor vehicle fatalities and other accidents, which led to the creation of the National Highway Traffic Safety Administration, a concerted effort was undertaken to improve emergency medical care in the prehospital setting.
Pittsburgh, Pennsylvania, Portland, Oregon and Seattle, Washington were early pioneers in prehospital emergency medical training. Pittsburgh's Freedom House paramedics are credited as the first EMT trainees in America. Baltimore's R. Adams Cowley is referred to as the father of trauma medicine. He devised the concept of integrated emergency care, designing the first civilian Medevac helicopter program and campaigning for a statewide EMS system. Portland's Leonard Rose, M.D., in cooperation with Buck Ambulance Service, instituted a cardiac training program and began to train other paramedics. In Seattle, the Medic One program at Harborview Medical Center and the University of Washington Medical Center, started by Leonard Cobb, M.D., began training firefighters in CPR in 1970. At the same time, the Los Angeles County Fire Department also began training some of their firefighters in emergency care. This was vividly portrayed in the television show, Emergency! which helped popularize the emergency medical service around the world. James O. Page is often referred to as the father of fire department-based EMS because of his roles as the LAFD chief in charge of the firefighter/paramedic program, the expert consultant for the show Emergency!, and the founder of JEMS.
The first paramedics began operating in the 1970's with expansion throughout the country since that time.
In 1972 the first civilian emergency medical helicopter transport service, Flight for Life opened in Denver, Colorado. Emergency medical helicopters or MEDEVACs were soon put into service elsewhere in the A.L.E.R.T. Kalispell, Montana areas and soon the rest of the United States. It is now routine to have paramedic and nurse staffed EMS helicopters in most major metropolitan areas. The vast majority of these aeromedical services are utilized for critical care air transport (inter-hospital) in addition to emergency medical services (pre-hospital).
Critical care transports are usually requested when a medical treatment facility (usually a smaller hospital) does not have the personnel, equipment, and/or services to definitively treat a patient. The patient is then rapidly transported to another medical treatment facility (usually a large hospital or health system located in close proximity to or within highly populated areas) that has the capability to either definitively treat or to extend or enhance treatment to a higher level. These critical care transports can occur by ground ambulance or aircraft. They are usually the reason why a nurse is needed in addition to a paramedic in the transport team. The nurse usually has experience and may be credentialled in critical care medicine. Recently, paramedics have received critical care medical training both in the initial paramedic certification course as well as continuing education courses such as the Critical Care Emergency Medical Transport Program (CCEMTP). This training has started to shift staffing of Critical Care transport units away from using nurses as often.
(Tactical) A little known arena that paramedics are found is with tactical law enforcement teams or better known as "S.W.A.T." Special Weapons and Tactics teams. These medics are usually from the EMS agency in the area and commissioned and trained to be a law enforcement officer and tactical operator in addition to his/her paramedic duties. The idea behind this comes from the military use of medics on special operations units. The purpose is to have advanced medical personnel that can perform dual roles as operator and medic and make entry into austere environments as a team member. In the event that an officer is injured (ie...critically by a gun shot wound etc...) the tactical medic is trained to deliver advanced emergency care immediately to the wounded officer. This training includes the ability to defend themselves with firearms or less than lethal weapons, protect the downed officer, provide cover and movement of the officer to a safe area, usually pre-designated, then administer immediate life saving medical care and arrange transport to definitive care. Transport is usually staged away from the incident and called up when the scene is secured. The tactical medic is also capable of treating any suspects, innocent victims or bystanders that may have been injured during the mission. This reduces liability for the law enforcement agency by having medics for their officers and immediate care for injured suspects. The shootings at Columbine (Colorado) High School served as a sentinel case that highlighted the need for integration of tactical emergency medical support into law enforcement special operations.
The employment of paramedics depends on the organizations that operate the ambulances and other emergency vehicles which they are deployed in. Paramedics responding to a typical emergency may work for the local fire department and arrive in a fire truck or an ambulance bearing the department's insignia, work for a local municipal government as a governmental "third service" EMS agency, work for a private organization such as a private ambulance and medical transport company, or work for a hospital or health care system.
[edit] Education
There are great disparities from nation to nation and within the U.S. as to what educational level and skills are required of Paramedics. The National Registry of Emergency Medical Technicians, a private certifying body, has attempted to standardize a method of registering EMTs and paramedics (based on the US Department of Transportation's national standard curriculum) for Paramedics in the US, but this has not been fully accepted by all states and even many who have continued to modify slightly the practices allowed to be performed by Paramedics.
Paramedic education programs can last as little as 8 months or as long as 4 years. A common degree program (Associates) is 2 years, often taught through a community college. Some universities now offer baccalaureate and masters level degrees in emergency medical services management, but as a relatively young industry, professional standards and education levels are still evolving. Regardless of educational path, the paramedic student must meet the same state requirements (course hours) to be eligible to take the certification exams, and as well as, if required by their state, the National Registry exams. In addition, most locales require paramedics to attend an ongoing schedule of refresher courses in order to maintain their license and/or certification.
Paramedics are educated to evaluate and manage the acute stages of nearly all medical conditions. Special emphasis is placed on recognizing and treating potentially life- treatening conditions such as myocardial infarction (heart attack), stroke, breathing problems, overdoses, traumatic injuries, and childbirth.
Specifically, paramedics are educated in airway management, such as intubation, including pharmacologically assisted intubation and increasingly in rapid sequence induction, advanced cardiac life support, including cardiac monitoring, 12-lead electrocardiograms, synchronized cardioversion and transcutaneous (through the skin) pacing; pediatric advanced life support, intravenous cannulation, intraosseus cannulation, needle chest decompression, needle cricothyroidotomy, and the administration of a wide range of medications such as morphine sulfate, benzodiazepines such as lorazepam, opioids and dextrose. In addition to certification (both state and National registry), most paramedics are required to be certified in PALS (Pediatric Advanced Life Support) or PPC (Pediatric Prehospital care) or PEPP (Pediatric Emergencies for the Prehospital Provider), PHTLS (Prehospital Trauma Life Support), BTLS (Basic Traum Life Support), and ACLS (Advanced Cardiac Life Support). All require additional education and certification from organizations such as the American Heart Association.
[edit] The Future
Gone are the days of untrained ambulance attendants. Many states forbid the staffing of ambulances by anyone with less than the EMT-Basic level of certification. In some states, registered nurses and physician's assistants are not permitted to provide patient care without training at the EMT-Basic level at a minimum. Those in need of emergency medical care have come to expect highly trained and educated medical professionals within four to nine minutes of the onset of their emergency. Rapid treatment and transport to a qualified medical facility follow the care given by paramedics in the field. In the most progressive systems in the U.S. the paramedics often screen patients to determine if a medical problem can be treated in the field, treated by a primary care clinic, or requires transport to an Emergency Department.
Since the early years of EMS development there have been firefighter-paramedics. Dr. Eugene Nagel [1] trained City of Miami firefighters as the first US paramedics to use invasive techniques and portable defibrillators with telemetry in 1967. Many communities today use these cross-trained firefighter paramedics.
The medical community is poised to shift towards a concept known as Evidence-Based Medicine [2]. Emergency-related practitioners are examining the effectiveness of advanced pre-hospital care. Proper use of this methodology evaluates the skills and knowledge of the practitioner, the clinical results, and the needs/expectations of the patient. Tying the parts together can result in better clinical outcomes, more satisfied patients, and better, more effective, standards of care for practitioners.
[edit] Skills performed by paramedics
Some of the many skills performed (as permitted by local protocol):
- Follow American Heart Association Advanced Cardiac Life Support (ACLS) guidelines (United States);
- Follow American Heart Association Pediatric Advanced Life Support (PALS) guidelines (United States);
- Follow International Trauma Life Support (ITLS) or Pre-Hospital Trauma Life Support (PHTLS) guidelines;
[edit] See also
- Ambulance
- Emergency Medical Services
- Paramedics in Canada
- Paramedics in France
- Paramedics in Germany
- Flight for Life
- Paramedics in South Africa
[edit] References
- Meisel, Zachary (Nov. 8, 2005). "Ding-a-Ling-a-Ling". Slate.
- UMMC. (n. d.). Tribute to R. Adams Cowley, MD. Retrieved December 30, 2005 from http://www.umm.edu/shocktrauma/history.html.
