Paramedics in the United States

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In the United States, a paramedic is an advanced level medical professional who responds to and treats medical emergencies and trauma outside of a hospital. Paramedics typically provide treatment on scene and during transportation to a hospital emergency department. Occasionally, paramedics treat conditions that do not require hospitalization, such as during public gatherings or other large events ("event standby"). They derive the legal authority to practice prehospital medical care in the field through the license of their physician medical director who is typically specialized in Emergency Medicine. Paramedics serve as an out-of-hospital extension of emergency services typically offered by medical doctors within the hospital emergency department. As advanced care providers, they are the team leaders of prehospital care, which involves assuming control of treatment and directing the functions performed by EMTs and other medical responders.

Example of an official shoulder emblem worn by paramedics to identify their advanced level of care.
Example of an official shoulder emblem worn by paramedics to identify their advanced level of care.

The National Highway Traffic Safety Administration (NHTSA) classifies medical responders as EMT-P (Paramedic), EMT-I (Intermediate), EMT-B (Basic), and First Responders. The paramedic is the most advanced level of EMT; however, in order to avoid confusion about levels of care, in practice the term "EMT" is typically reserved for Emergency Medical Technicians below the paramedic level. In the professional vernacular, paramedic is treated as a distinct medical title that is not synonymous with EMT, and official emblems to identify the advanced level of care have often codified this designation. Paramedics in the United States, working independently and under the direction of emergency medical control physicians, generally provide the most advanced level of emergency medical care available to the public outside of a hospital setting, although in some cases EMS flight crews utilize advanced level providers such as physicians.[1]

Typical view of the defibrillator operator. The leader is at the head of the patient, administrating oxygen. Note how the head of the patient in secured between the leader's knees. The defibrillation patches are on.
Typical view of the defibrillator operator. The leader is at the head of the patient, administrating oxygen. Note how the head of the patient in secured between the leader's knees. The defibrillation patches are on.

Contents

[edit] Employment

Paramedics are employed by various public and private emergency service providers. These include private ambulance services, fire departments, the 9-1-1 system, hospitals, law enforcement agencies, the military, various EMS-specific, and "third service" public safety agencies. Paramedics may respond to medical incidents in an ambulance, rescue vehicle, helicopter, fixed-wing aircraft, motorcycle, or fire suppression apparatus.

Paramedics may also be employed in medical fields that do not involve transportation of patients. Such positions include offshore drilling platforms, phlebotomy, blood banks, research labs, educational fields, law enforcement and hospitals.

Critical care transporters move patients by ground ambulance or aircraft to a medical treatment facility. A nurse credentialled in critical care medicine may accompany the patient. Other critical care units use paramedics who have received critical care medical training, or continuing education courses in the Critical Care Emergency Medical Transport Program (CCEMTP).

Tactical paramedics work on law enforcement teams (SWAT). These medics, usually from the EMS agency in the area, are commissioned and trained to be tactical operators in law enforcement, in addition to paramedic duties. Advanced medical personnel perform dual roles as operator and medic on the teams. Such an officer is immediately available to deliver advanced emergency care to other injured officers, suspects, innocent victims and bystanders.

In-the-Hospital paramedics are increasingly employed in the emergency departments and intensive care units due to the nursing shortage. In emergent situations, paramedics are generally accustomed to practicing with greater latitude and autonomy than Registered Nurses due to their specialized interventional training, which emphasizes discretionary decisions and treatment without mandatory physician consultation.[2]

In the U.S., paramedic salaries can range from zero, for unpaid volunteer positions, to as much as $90,000 a year depending on location, experience, and supervisory responsibilities[citation needed].

[edit] Skills performed by paramedics

[edit] Education

The education and skills required of paramedics vary by state. The NHTSA designs and specifies a National Standard Curriculum [3] for EMT training. Most paramedic education and certifying programs require that a student is at a minimum educated and trained to the National Standard Curriculum for a particular skill level. The National Registry of Emergency Medical Technicians (NREMT) is a private, central certifying entity whose primary purpose is to maintain a national standard. NREMT also provides certification information for paramedics who relocate to another state [4] .

Paramedic education programs can be as short as 8 months or as long as 1 year. A common associates degree program is 2 years, often taught through a community college. Paramedic certification courses normally take about one year. Degree programs are an option with two year associates degree programs being the standard but a limited number four year bachelor degree programs exist. Regardless of educational path, all paramedic students must meet the same state requirements to take the certification exams, possibly including the National Registry exams. In addition, most locales require that paramedics attend ongoing refresher courses to maintain their license or certification.

In the field, the levels of training are separated into BLS (Basic Life Support), ILS (Intermediate Life Support) and ALS (Advanced Life Support) units. Basic-level skills include CPR, first aid, airway management, oxygen administration, spinal immobilization, traction splinting, bleeding control and splinting. Intermediate skills include IV therapy, endotracheal intubation and initial cardiac drug therapy. In addition to the basic and intermediate skills, the paramedic is also educated in EKG interpretation, advanced respiratory support and airway skills, RSI, pharmacology, trauma resuscitation, pediatric life support and advanced cardiac life support. Most states, and the National Registry, require ongoing continuing education and verification of clinical skills capability for a paramedic to maintain certification. A few states have permanent certification, except for issues involving gross negligence and malpractice.

Paramedics are educated to evaluate and manage the acute stages of 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 including intubation, pharmacologically assisted intubation, and increasingly 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; intraosseous infusion; needle chest decompression; needle cricothyroidotomy; and the administration of a wide range of medications such as morphine sulfate and other opioids, benzodiazepines such as lorazepam, and dextrose.

In addition to state and national registry certifications, most paramedics are required to be certified in PALS (Pediatric Advanced Life Support), PPC (Pediatric Prehospital care) or PEPP (Pediatric Emergencies for the Prehospital Provider); PHTLS (Prehospital Trauma Life Support); ITLS (International Trauma Life Support); and ACLS (Advanced Cardiac Life Support). These additional requirements have education and certification from organizations such as the American Heart Association.

Paramedic programs are classified into two categories, accredited and non-accredited. Programs seeking accreditation go through a rigorous process that involves a stringent self-evaluation based on the Committee on Accredi­tation of Educational Programs(CoAEMSP) standards and guidelines and a two-day site visit by two reviewers (usually a paramedic educator and a physician) who conduct numerous interviews and verify every aspect of the application and self-evaluation. CoAEMSP is apart of the Commission on Accreditation of Allied Health Education Programs (CAAHEP).[5]

The National Registry of Emergency Medical Technicians (NREMT) has recently announced that beginning in 2012, they will no longer be certifying paramedics who did not come through an accredited program. Most accredited programs are done through local community college. Although, many states have few accredited programs. For example, Michigan only has two accredited programs in the entire state (Lansing Community College and Huron Valley Ambulance).

In many states NREMT certification is all that is required to receive your license.

[edit] History

Bicycle paramedics, Los Angeles, California.
Bicycle paramedics, Los Angeles, California.

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.

Jacksonville, Florida, Pittsburgh, Pennsylvania, Portland, Oregon and Seattle, Washington were among early pioneers in prehospital emergency medical training.

The Jacksonville Rescue Squad was organized in February, 1958 following the tragic death of a young boy in Elizabeth Lake. Police Chief Clyde R. Cook, realized the need for such a unit in Jacksonville. The majority of the members were uniformed members of the police and fire departments, civilians, and military personnel from Camp Lejeune and New River.[citation needed]

Pittsburgh's Freedom House paramedics are credited as the first EMT trainees in America. Pittsburgh's Peter Safar is referred to as the father of CPR. In 1967, he began training unemployed African-American men in what later became Freedom House Ambulance Service, the first paramedic squadron in the United States. [6] [7] Dr. Eugene Nagel [8] trained City of Miami firefighters as the first US paramedics to use invasive techniques and portable defibrillators with telemetry in 1967. Baltimore's R. Adams Cowley, the father of trauma medicine, 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 training 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 (LAFD) also began training 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 LACoFD 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 1970s 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).

The 1999 Columbine High School massacre served as a sentinel case highlighting the need to integrate tactical emergency medical support into law enforcement special operations.

[edit] Issues

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[edit] Staffing

Much like the nursing shortage and the shortage of other health care professionals, there is a shortage of paramedics in some areas. Between the years 2002 and 2007, the need for paramedics has increased as more fire departments add paramedics cross-trained as firefighters[citation needed]. The educational requirements--about two years of education and training--and relatively low salary are pushing potential and current paramedics into other health care fields. At the associate and baccalaureate level of paramedic education, becoming a functioning paramedic requires approximately the same time and educational commitment as nursing, respiratory therapists, radiologic technologists (X-RAY Techs)[citation needed], but tends to pay significantly less and provide far fewer job options outside of an EMS system as well as fewer upward career and educational opportunities.

[edit] Lack of Professional Equality

Paramedics can experience professional inequality in pay, job demands and prestige. Where state law and hospital policy allow, paramedics may work in hospital emergency departments or intensive care units. Hospitals typically pay by credential, paying an EMT-P license less than a RN license. (While registered nurses and paramedics can be seen performing the same types of tasks, the registered nurse has completed a longer course of training - usually four years of university education and clinical instruction - and is knowllegable regarding health care in all stages of disease and injury, as opposed to emergency care only.)In the EMS system, job demands for paramedics vary by agency and geography. The workload of paramedics in a metropolitan city is more demanding than the workload in smaller towns, for example. Finally, the public and many health professionals generally view all EMT personnel in the same category. The accomplishment of attaining the highest certification within EMT ranks is often not recognized by the people a paramedic will serve.

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 and drugs, and severe weather conditions. They are highly adept at assessing patients using their own instincts and senses, augmented by their education and experience.

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. Another factor for this perception is that prior to 1970 the paramedic, at least as currently defined, did not exist. Due to the relative infancy of paramedics as educated health care providers, they continually struggle to be seen as "clinicians" instead of "technicians."

Currently, the only options available for a paramedic to "further" their career is to pursue a nursing or doctorate degree, to become an instructor, or to pursue government-level disaster management positions (such as in local or federal disaster agencies like FEMA).

Fire Departments rarely provide a "career ladder" beyond lieutenant or captain within the department for paramedics unless they become cross trained as fire fighters. A key factor in the in-equality in the fire service between paramedics and traditional firefighters is the International Association of Fire-Fighters (IAFF) which many believe to have pushed its own labor based agenda (creation of jobs and expansion of fire departments) at the expense of the EMS profession as a whole[citation needed].

Recently, many states have started a professional development program for veteran paramedics. Called Critical Care or Advanced Practice Paramedics, these paramedics attend additional classroom and cadavar labs and learn advanced assessment and treatment skills, including certain field surgical interventions (chest tube placement, placement of central lines, pericardiocentesis, complex mechanical ventilation, and surgical airway access). Many states have plans to implement this, but most, including Tennessee, are still in the initial planning and train-the-trainer stages. These programs will have the most impact in smaller, rural counties where transport times to Trauma Centers and Specialty Hospitals may be beyond the Golden Hour principal. These paramedics are intended to work on Critical Care units, such as those employed by specialty pediatric and adult transport teams. New York, New Jersey, Maine, and Alaska are states with these programs in place. In addition, there is now a Flight Paramedic Certification (FP-C), intended for those paramedics who want to learn additional critical transport skills for use in Aeromedical transport. In particular, CAMTS and CAMS certifications require that Aeromedical and Ground Transport services encourage their personnel to seek these certifications.

[edit] Call Related Stress

EMS professionals are unique among healthcare workers in that they operate independently, working in small, isolated teams to bring clinical intervention to austere and potentially dangerous non-clinical environments. The demands associated with this role may include coping with raw exposure to trauma, sudden tragedy, human suffering and personal peril. Paramedics are expected to remain calm in emergency situations. They are counted on to be supportive toward distraught bystanders and frightened patients freshly exposed to catastrophic events. Dealing with grief-stricken individuals presents special emotional challenges, and treating sick or injured children is often ranked by paramedics as one of the most stressful parts of the job. [9]

Some of the strenuous physical activities performed by Paramedics and the environmental conditions experienced are: Working outdoors in all kinds of weather; climbing stairs; using such devices as stair chair or ambulance stretcher; carrying equipment and patients on ambulance stretchers; working for extended periods during the day or night in ambulances; driving an ambulance in all kinds of weather; working in confined spaces such as under vehicles, trains, and buildings; working at hazardous material scenes such as a chemical spill or an industrial fire or accident; treating patients at heights such as rooftops, bridges or elevated highways; and working in varying light conditions. [10]

Paramedic duties include treating patients who may have infectious and communicable diseases in hostile environments that make biohazard precautions difficult to maintain. For example, a paramedic may need to urgently start an IV under poor lighting or in the back of a moving ambulance, thus exposing himself to sharp implements and infectious blood in less than clinical conditions. Paramedics may be called without warning to perform emergency treatment and invasive procedures within the contaminated home of an infectious patient. Exposure to blood-born pathogens such as Hepatitis C, HIV/AIDS and tuberculosis from accidental needle punctures, blood sprays and coughing/spitting is an ever present risk.

Violent crime scenes can be another source of stress for paramedics. In some high-crime urban EMS systems, paramedics and EMTs wear ballistic vests.

[edit] Political

While the history of firefighter paramedics is almost as long as the history of EMS itself, there is significant debate on what positive influence, if any, fire unions will have on EMS as a whole. In fact, the IAFC and other fire related organizations are actively fighting against degree requirements at the national level for all new paramedics[11] (similar to RNs), as well as blocking the formation of a National Emergency Medical Services Administration (NEMSA) similar to the National Fire Administration[citation needed]. While NEMSA would have unified the divisions of federal EMS support under one administration--opening up funding and standardization opportunities--it would have significantly detracted from the exploitation[dubious – discuss] of EMS by the fire service . This effort was abandoned after several letters and much political lobbying by the political savvy IAFF and IAFC[citation needed]. Finally, less that 4% of non-fire based EMS received federal grant monies[citation needed], the remaining going to fire-based EMS. Therefore the future role and the impact of fire-based EMS on the EMS profession is both heated, and vital, to the future of EMS.

[edit] See also

[edit] References

  1. ^ Keith Holtermann, Jean Johnson, et al. (April 2006). National Reregistration and the Continuing Competence of EMT-Paramedics. Retrieved on 2007-08-02.
  2. ^ Comparison of Paramedics and Emergency Nurses. Retrieved on 2008-02-03.
  3. ^ National Standard Curriculum. Retrieved on 2007-08-08.
  4. ^ State Office Information. Retrieved on 2007-08-08.
  5. ^ NREMT Sets Deadline for Education Programs
  6. ^ Send Freedom House!. Retrieved on 2007-06-26.
  7. ^ "Pitt Magazine", Spring, 2007, pp. 6. 
  8. ^ Dr Eugene L. Nagel. Retrieved on 2007-08-06.
  9. ^ EMS: Coping with the Unthinkable. Retrieved on 2008-03-08.
  10. ^ NYC DAS Paramedic Job Description. Retrieved on 2008-02-03.
  11. ^ Formal Comments on the National EMS Education Standards, Draft 1.0

[edit] External links

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