A paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma.[1] The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as cycle response. Paramedics provide out-of-hospital treatment and some diagnostic services,[2][3] although some may undertake hospital-based roles, such as in the treatment of minor injuries.
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Throughout the evolution of paramedic care, there has been an ongoing association with military conflict. One of the first indications of a formal process for managing injured people dates from the Imperial Legions of Rome, where aging Centurions, no longer able to fight, were given the task of organizing the removal of the wounded from the battlefield and providing some form of care. Such individuals, although not physicians, were probably among the world's earliest surgeons by default, being required to suture wounds and complete amputations. A similar situation existed in the Crusades, with the Knights Hospitallers of the Order of St. John of Jerusalem filling a similar function; this organisation continued, and evolved into what is now known throughout the Commonwealth of Nations as the St. John Ambulance.
While civilian communities had organized ways to deal with the care and transportation of the sick and dying as far back as the bubonic plague in London between 1598 and 1665, such arrangements were typically temporary. In time, however, these arrangements began to formalize and become permanent. During the American Civil War, Jonathan Letterman devised a system of mobile field hospitals employing the first uses of the principles of triage. After returning home, some veterans began to attempt to apply what had they had seen on the battlefield to their own communities, and commenced the creation of volunteer life-saving squads and ambulance corps.
These early developments in formalised ambulance services were decided at local levels, and this led to services being provided by diverse operators such as the local hospital, police, fire brigade, or even funeral directors who often possessed the only local transport allowing a passenger to lie down. In most cases these ambulances were operated by drivers and attendants with little or no medical training, and it was some time before formal training began to appear in some units. An early example was the members of the Toronto Police Ambulance Service receiving a mandatory five days of training from St. John as early as 1889.[4]
Prior to World War I motorized ambulances started to be developed, but once they proved their effectiveness on the battlefield during the war the concept spread rapidly to civilian systems. In terms of advanced skills, once again the military led the way. During World War II and the Korean War battlefield medics administered painkilling narcotics by injection in emergency situations, and pharmacists' mates on warships were permitted to do even more without the guidance of a physician. The Korean War also marked the first widespread use of helicopters to evacuate the wounded from forward positions to medical units, leading to the rise of the term "medivac". These innovations would not find their way into the civilian sphere for nearly twenty more years.
By the early 1960s experiments in improving care had begun in some civilian centres. One early experiment involved the provision of pre-hospital cardiac care by physicians in Belfast, Northern Ireland, in 1966.[5] This was repeated in Toronto, Canada in 1968 using a single ambulance called Cardiac One, which was staffed by a regular ambulance crew, along with a hospital intern to perform the advanced procedures. While both of these experiments had certain levels of success, the technology had not yet reached a sufficiently advanced level to be fully effective; for example, the Toronto portable defibrillator and heart monitor was powered by lead-acid car batteries, and weighed around 45 kilograms (99 lb).
In 1966 a report called Accidental Death and Disability: The Neglected Disease of Modern Society—commonly known as The White Paper—was published in the United States. This paper presented data showing that soldiers who were seriously wounded on the battlefields during the Vietnam War had a better survival rate than individuals who were seriously injured in motor vehicle accidents on California's freeways.[6] Key factors allowing the victim to survive the journey to definitive care such as a hospital were stated to be comprehensive trauma care, rapid transport to designated trauma facilities, and the presence of medical corpsman who were trained to perform certain critical advanced medical procedures such as fluid replacement and airway management.
As a result of the The White Paper the Federal government moved to develop minimum standards for ambulance attendant training, ambulance equipment and vehicle design. These new standards were incorporated into Federal Highway Safety legislation and the state were advised to either adopt these standards into state laws or risk a reduction in Federal highway safety fundings. The "White Paper" also prompted the inception of of a number of emergency medical service (EMS)pilot units across the US including paramedic programs. The success of these units led to a rapid transition to make them fully operational, with the first paramedic program being in Miami, Florida.
New York City's Saint Vincent's Hospital developed America's first Mobile Coronary Care Unit (MCCU) under the medical direction of William Grace, MD and was based on Dr. Frank Pantridge's Belfast, Northern Ireland MCCU project. In 1967 Eugene Nagle, MD and Jim Hirschmann, MD helped pioneer America's first EKG telemetry transmission to a hospital and then in 1968, a functional paramedic program in conjunction with the City of Miami Fire Department. In 1969. the City of Columbus Fire Services joined together with the Ohio State University Medical Center and developed the "HEARTMOBILE" paramedic program under the medical direction of James Warren, MD and Richard Lewis, MD. In 1969. the Haywood County (NC) Volunteer Rescue Squad developed a paramedic program under the medical direction of Ralph Fleicher, MD. In 1969, the initial Los Angeles paramedic training program was instituted in conjunction with Harbor General Hospital under the medical direction of Michael Criley, MD and James Lewis, MD. In 1969, the Seattle "Medic 1" paramedic program was developed in conjunction with the Harborview Medical Center under the medical direction of Leonard, Cobb. The Marietta (GA) initial paramedic project was instituted in the Fall of 1970 in conjunction with Kennestone Hospital and Metro Ambulance Service, Inc. under the medical direction of Luther Fortson, MD. The Los Angeles county and city established paramedic programs following the passage of The Wedworth-Townsend Act in 1970. This was followed by other cities and states passing their own paramedic bills, leading to the formation of services across the US. Many other countries also followed suit, with paramedic units quickly being formed around the world.
In the military, however, the required telemetry and miniaturization technologies were more advanced, particularly due to initiatives such as the space program, but it would take several more years before these technologies drifted through to civilian applications. In North America, physicians were judged to be too expensive to be used in the pre-hospital setting, although such initiatives were implemented, and sometimes still operate, in European countries and Latin America.
While doing background research at Los Angeles' UCLA Harbor Medical Center for a proposed new show about doctors, television producer Robert A. Cinader, working for Jack Webb, happened to encounter "firemen who spoke like doctors and worked with them". This concept developed into the television series Emergency!, which ran from 1972 to 1979, portraying the exploits of this new profession called paramedics. The show gained popularity with emergency services personnel, the medical community, and the general public. When the show first aired in 1972, there were just six paramedic units operating in three pilot programs in the whole of the US, and the term paramedic was essentially unknown. By the time the program ended in 1979, there were paramedics operating in all fifty states. The show's technical advisor, James O. Page, was a pioneer of paramedicine and responsible for the UCLA paramedic program; he would go on to help establish paramedic programs throughout the US, and was the founding publisher of the Journal of Emergency Medical Services (JEMS). The JEMS magazine creation resulted from Page's previous purchase of the "PARAMEDICS International" magazine.
Throughout the 1970s and 80s, the paramedic field continued to evolve, with a shift in emphasis from patient transport to treatment both on scene and en-route to hospitals. This led to some services changing their descriptions from "ambulance services" to "emergency medical services".
The training, knowledge-base, and skill sets of both paramedics and emergency medical technicians (EMTs) were typically determined by local medical directors, what it was felt the community needed, and what was affordable. There were also large differences between localities in the amount and type of training required, and how it would be provided. This ranged from in-service training in local systems, through community colleges, and up to university level education. This emphasis on increasing qualifications has followed the progression of other health professions such as nursing, which also progressed from on the job training to university level qualifications.
The variations in educational approaches and standards required for paramedics has led to large differences in the required qualifications between locations—both within individual countries and from country to country. This has led to many countries passing laws to protect the title of "paramedic" (or its local equivalent) from use by anyone except those qualified and experienced to a defined standard. This usually means that paramedics must be registered with the appropriate body in their country, for example all paramedics in the United Kingdom must by registered with the Health Professions Council in order to call themselves a paramedic. In the United States, a similar system is operated by the National Registry of Emergency Medical Technicians (NREMT), although this is only accepted by forty of the fifty states.
As paramedicine has evolved a great deal of both the curriculum and skill set has existed in a state of flux. Requirements often originated and evolved at the local level, and were based upon the preferences of physician advisers and medical directors. Recommended treatments would change regularly, often changing more like a fashion than a scientific discipline. Associated technologies also rapidly evolved and changed, with medical equipment manufacturers having to adapt equipment that worked adequately the hospital environment to be able to cope with the less controlled pre-hospital environment.
Physicians began to take more interest in paramedics from a research perspective as well. By about 1990, the fluctuating trends began to diminish, being replaced by outcomes-based research. This research then drove further evolution of the practice of both paramedics and the emergency physicians who oversaw their work, with changes to procedures and protocols occurring only after significant research demonstrated their need and effectiveness (an example being ACLS). Such changes affected everything from simple procedures, such as CPR, to changes in drug protocols. As the profession grew, some paramedics went on to become not just research participants, but researchers in their own right, with their own projects and journal publications.
Changes in procedures also included the manner in which the work of paramedics was overseen and managed. In the early days medical control and oversight was direct and immediate, with paramedics calling into a local hospital and receiving orders for every individual procedure or drug. While this still occurs in some jurisdictions, it has become increasingly rare, with physicians building an increasing confidence and trust in the work of paramedics. Day-to-day operations largely moved from direct and immediate medical control to pre-written protocols or standing orders, with the paramedic typically seeking advice after the options in the standing orders had been exhausted.
While the evolution of paramedicine described above is focused largely on the US, many other countries followed a similar pattern, although often with significant variations. Canada, for example, attempted a pilot paramedic training program at Queen's University, Kingston, Ontario, in 1972. The program, which intended to upgrade the then mandatory 160 hours of training for ambulance attendants, was found to be too costly and premature. The program was abandoned after two years, and it was more than a decade before the legislative authority for its graduates to practice was put into place. An alternative program which provided 1,400 hours of training at the community college level prior to commencing employment was then tried, and made mandatory in 1977, with formal certification examinations being introduced in 1978. Similar programs occurred at roughly the same time in Alberta and British Columbia, with other Canadian provinces gradually following, but with their own education and certification requirements. Advanced Care Paramedics were not introduced until 1984, when Toronto trained its first group internally, before the process spread across the country. By 2010 the Ontario system involved a two year community college based program, including both hospital and field clinical components, prior to designation as a Primary Care Paramedic, although it is starting to head towards a university degree-based program. Some services, such as Toronto EMS, continue to train advanced care paramedics internally.
In the United Kingdom, ambulances became largely municipal services shortly after the end of World War II. Training was frequently conducted internally, although national levels of coordination led to more standardization of staff training. As of 2010 public ambulance services were operated by regional entities, most often trusts, under the authority of the National Health Service, with significant standardization of training and skills. The UK model utilizes two levels of ambulance staff, internally trained Ambulance Technicians, which are similar to EMTs in the US, and paramedics with advanced life support skills. Initially paramedics were mainly trained internally, with experienced ambulance technicians often progressing to the role of paramedic. Increasingly, however, university qualifications are being expected for paramedics, with the entry level being an Honours Bachelor of Science degree in Pre-Hospital or Paramedic Care. Some British paramedics have gone on to become Paramedic Practitioners, a role that practices independently in the pre-hospital environment in a capacity similar to that of a nurse practitioner, but with more of an acute care orientation.
Paramedicine continues to grow and evolve into a formal profession in its own right, complete with its own standards and body of knowledge, and in many locations paramedics have formed their own professional bodies. The early technicians with limited training, performing a small and specific set of procedures, has become a profession requiring a university qualification in countries such as Australia, South Africa, and the UK, and increasingly so in the US and Canada. In some locations paramedics are evolving into a second tier medical practitioner and being granted the legal status of self-regulated health professionals. This requires them to meet set standards of education and proficiency, deals with complaints regarding individual practitioners, and will usually involve government regulation.
Paramedics are employed by a variety of different organizations, and the services provided by paramedics may occur under differing organizational structures, depending on the part of the world. A new and evolving role for paramedics involves the expansion of their practice into the provision of relatively basic primary health care and assessment services.
Some paramedics have begun to specialize their practice, frequently in association with the environment in which they will work. Some early examples of this involved aviation medicine and the use of helicopters, and the transfer of critical care patients between facilities. While some jurisdictions still use physicians, nurses, and technicians for transporting patients, increasingly this role falls to specialized senior and experienced paramedics. Other areas of specialization include such roles as tactical paramedics working in police units, marine paramedics, hazardous materials (Hazmat) teams, Heavy Urban Search and Rescue, and paramedics on offshore oil platforms, oil and mineral exploration teams, and in the military.
The majority of paramedics are employed by the municipal emergency medical service for their area, although this employer could be itself be working under a number of models, including a specific autonomous public ambulance service, a fire department, a hospital based service or a private company working under contract. There are also legions of paramedics who volunteer for backcountry rescue teams, small town rescue squads, and the like.
The provision of municipal ambulance services, and paramedics, can vary by area, even within the same country or state. For instance, in Canada, the province of British Columbia operates a province-wide service (the British Columbia Ambulance Service) whereas in Ontario, the service is provided by each municipality, either as a disctinct service, linked to the fire brigade, or contracted out to a third party.
While there are varying degrees of training and expectations around the world, a general set of skills shared by essentially all paramedics and EMTs includes:
Paramedics in most jurisdictions administer a variety of emergency medications. The specific medications they are permitted to administer vary widely, based on local standards of care and legal restrictions, and physician or medical director preferences. For an accurate description of permitted drugs or procedures in a given location, it is necessary to contact that jurisdiction directly. A representative list of medications may commonly include:
As described above, many jurisdictions have different levels of paramedic training, leading to variations in what procedures different paramedics may perform depending upon their qualifications. Three common general divisions of paramedic training are the basic technician, general paramedic or advanced technician, and advanced paramedic. Common skills that these three certification levels may practice are summarized in the table below. The skills for the higher levels automatically also assume those listed for lower levels.
| Treatment issue | Common technician skills | Paramedic/advanced technician skills | Advanced paramedic skills |
|---|---|---|---|
| Airway management | Assessment, manual repositioning, oropharyngeal and nasopharyngeal airway adjuncts, manual removal of obstructions, suctioning | Tracheal intubation, and sometimes nasopharyngeal intubation, advanced airway management, ETT, LMA, and combitube, deep suctioning, use of Magill forceps | Rapid sequence induction, surgical airway procedures including needle cricothyrotomy and surgical cricothyrotomy |
| Breathing | Assessment (rate, effort, symmetry, skin color), obstructed airway maneuver, passive oxygen administration by nasal canula, rebreathing and non-rebreathing mask, active oxygen administration by bag valve mask (BVM) | Pulse oximetry, active oxygen administration by endotracheal tube or other device using BVM, side stream, or inline end tidal carbon dioxide, capnography | Use of mechanical transport ventilators, active oxygen administration by surgical airway, decompression of chest cavity using needle or valve device (needle thoracotomy) |
| Circulation | Assessment of pulse (rate, rhythm, volume), blood pressure, skin color, and capillary refill, patient positioning to enhance circulation, recognition and control of hemorrhage of all types using direct and indirect pressure, tourniquets, and obtaining intravenous access | Ability to interpret assessment findings in terms of levels of perfusion, intravenous fluid replacement, use of vasoconstriction drugs | Intravenous plasma volume expanders, blood transfusion, intraosseous (IO) cannulation (placement of needle into marrow space of a large bone), central venous access (using central venous catheter by way of external jugular or subclavian) |
| Cardiac arrest | Cardiopulmonary resuscitation, airway management, manual ventilation with BVM, automatic external defibrillator | Dynamic resuscitation including intubation, drug administration (includes antiarrhythmics), ECG interpretation (may be limited to three-lead), semi-automatic and/or manual defibrillator, cardioversion, and external cardiac pacing | Expanded drug therapy options, ECG interpretation (twelve-lead), manual defibrillator, synchronized mechanical or chemical cardioversion, external pacing of the heart |
| Cardiac Monitoring | Cardiac monitoring and interpretation of ECGs | Twelve-lead ECG monitoring and interpretation | Eighteen-lead ECG monitoring and interpretation |
| Drug administration | Oral, nebulized, and intramuscular injection | Intramuscular, subcutaneous, intravenous injection (bolus), intravenous drip, transdermal and intraosseous | endotracheal tube, rectal tube, infusion pump |
| Drug types permitted | Low-risk and immediate requirements, e.g., aspirin and nitroglycerin (chest pain), oral glucose and glucagon (diabetes), epinephrine (allergic reaction), salbutamol (asthma), sometimes naloxone (narcotic overdose) | Considerable expansion of permitted drugs, but still typically limited to about twenty, including analgesics (may include narcotics), antiarrhythmics, major cardiac resuscitation drugs, bronchodilators, vasoconstrictors, sedatives | Significantly expanded drug list (up to sixty); in some jurisdictions advanced levels of paramedics are permitted to administer any drug, as long as they are familiar with it, and may have limited authority to prescribe |
| Patient assessment | Basic physical assessment, vital signs, history of general and current condition | More detailed physical assessment and history, auscultation, interpretation of assessment findings, ECG interpretation, glucometry, capnography, pulse oximetry | Interpretation of lab results, interpretation of chest x-rays, interpretation of cranial CT scan, limited diagnosis (e.g. rule out fracture using Ottawa ankle rules), ultrasonography[7] |
| Wound management | Assessment, control of bleeding, application of pressure dressings and other types of dressings | Wound cleansing, wound closure with butterfly stitches, suturing |
The medicolegal framework for paramedics is highly dependant on the overall structure of emergency medical services in the territory where they are working.
In places where paramedics are recognized health care professionals registered with an appropriate body, they can conduct all procedures authorised for their profession, including the administration of prescription medication, and are personally answerable to a regulator. For example, in the United Kingdom, the Health Professions Council regulates paramedics and can censure or strike a paramedic from the register. In some cases paramedics may gain further qualifications to extend their status to that of a paramedic practitioner, which provides the right to prescribe, rather than just administer, medication.
In other places paramedics operate as a direct extension of a physician medical director, and practice as an extension of the medical director's license to practice medicine. The authority to practice in this semi-autonomous manner is granted in the form of standing order protocols (off-line medical control), and, in some cases, direct physician consultation via phone or radio (on-line medical control). Under this paradigm, paramedics effectively assume the role of out-of-hospital field agents to regional emergency physicians, with independent clinical decision-making authority that is typically enjoyed only by expert clinicians within the hospital setting. In some locations paramedics are only permitted to practice many advanced skills while assisting a physician who is physically present, except for immediately life-threatening emergencies.
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