Paramedic

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ACTAS Paramedics-photo.jpg
Paramedics of the Australian Capital Territory Ambulance Service during training
Occupation
NamesParamedic
Occupation type
Profession
Activity sectors
Health care
Description
Fields of
employment
Ambulance; Hospital; Pre-Hospital; Transport
Related jobs
Emergency medical technician

A paramedic is a registered healthcare professional who works autonomously across a range of health and care settings and may specialise in clinical practice, as well as in education, leadership, and research.

Contents

Not all ambulance personnel are paramedics. In some English-speaking countries, there is an official distinction between paramedics and emergency medical technicians (or emergency care assistants), in which paramedics have additional educational requirements and scope of practice. [1]

Duties and functions

The paramedic role is closely related to other healthcare positions, especially the emergency medical technician, with paramedics often being at a higher grade with more responsibility and autonomy following substantially greater education and training. [2] The primary role of a paramedic is to stabilize people with life-threatening injuries and transport these patients to a higher level of care (typically an emergency department). Due to the nature of their job, paramedics work in many environments, including roadways, people's homes, and depending on their qualifications, wilderness environments, hospitals, aircraft, and with SWAT teams during police operations. Paramedics also work in non-emergency situations, such as transporting chronically ill patients to and from treatment centers and in some areas, address social determinants of health and provide in-home care to ill patients at risk of hospitalization (a practice known as community paramedicine [3] [4] ).

The role of a paramedic varies widely across the world, as EMS providers operate with many different models of care. In the Anglo-American model, paramedics are autonomous decision-makers. In some countries such as the United Kingdom and South Africa, the paramedic role has developed into an autonomous health profession. In the Franco-German model, ambulance care is led by physicians. In some versions of this model, such as France, there is no direct equivalent to a paramedic. Ambulance staff have either the more advanced qualifications of a physician or less advanced training in first aid. In other versions of the Franco-German model, such as Germany, paramedics do exist. Their role is to support a physician in the field, in a role more akin to a hospital nurse, rather than operating with clinical autonomy.

The development of the profession has been a gradual move from simply transporting patients to hospital, to more advanced treatments in the field. In some countries, the paramedic may take on the role as part of a system to prevent hospitalisation entirely and, through practitioners, are able to prescribe certain medications, or undertaking 'see and refer' visits, where the paramedic directly refers a patient to specialist services without taking them to hospital. [5]

Occupational hazards

Paramedics are exposed to a variety of hazards such as lifting patients and equipment, treating those with infectious disease, handling hazardous substances, and transportation via ground or air vehicles. Employers can prevent occupational illness or injury by providing safe patient handling equipment, implementing a training program to educate paramedics on job hazards, and supplying PPE such as respirators, gloves, and isolation gowns when dealing with biological hazards. [6]

Infectious disease has become a major concern, in light of the COVID-19 pandemic. In response, the U.S. Centers for Disease Control and Prevention and other agencies and organizations have issued guidance regarding workplace hazard controls for COVID-19. Some specific recommendations include modified call queries, symptom screening, universal PPE use, hand hygiene, physical distancing, and stringent disinfection protocols. [7] [8] Research on ambulance ventilation systems found that aerosols often recirculate throughout the compartment, creating a health hazard for paramedics when transporting sick patients capable of airborne transmission. [9] Unidirectional airflow design can better protect workers. [9]

History

Early history

Throughout the evolution of pre-hospitalisation 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 Hospitaller 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 and as the Order of Malta Ambulance Corps in the Republic of Ireland and various countries.

Early ambulance services

While civilian communities had organized ways to deal with prehospitalisation 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 ad hoc and 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.

German Red Cross paramedics training in 1931 Bundesarchiv Bild 102-11536, Sanitater bei DRK-Ubung.jpg
German Red Cross paramedics training in 1931
Ambulance of the Magen David Adom in Israel, 6 June 1948 Magen David Adom1948.jpg
Ambulance of the Magen David Adom in Israel, 6 June 1948

These early developments in formalized 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. [10]

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 "medevac". These innovations would not find their way into the civilian sphere for nearly twenty more years.

Prehospital emergency medical care

By the early 1960s experiments in improving medical 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. [11] 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).

EMTs caring for a collapsed woman in New York Woman collapses in the East Village of New York.jpg
EMTs caring for a collapsed woman in New York

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. [12] Key factors contributing to victim survival in transport to definitive care such as a hospital were identified as comprehensive trauma care, rapid transport to designated trauma facilities, and the presence of medical corpsmen who were trained to perform certain critical advanced medical procedures such as fluid replacement and airway management.

As a result of The White Paper, the US government moved to develop minimum standards for ambulance training, ambulance equipment and vehicle design. These new standards were incorporated into Federal Highway Safety legislation and the states were advised to either adopt these standards into state laws or risk a reduction in Federal highway safety funding. The "White Paper" also prompted the inception 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.

Freedom House Ambulance Service was the first civilian emergency medical service in the United States to be staffed by paramedics, most of whom were black. New York City's Saint Vincent's Hospital developed the United States' first Mobile Coronary Care Unit (MCCU) under the medical direction of William Grace, MD, and based on Frank Pantridge's MCCU project in Belfast, Northern Ireland.[ when? ] In 1967, Eugene Nagle, MD and Jim Hirschmann, MD helped pioneer the United States' 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 with the Ohio State University Medical Center to develop 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 (then called Mobile Intensive Care Technicians) under the medical direction of Ralph Feichter, MD. In 1969, the initial Los Angeles paramedic training program was instituted in conjunction with Harbor General Hospital, now Harbor–UCLA Medical Center, under the medical direction of J. 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, MD. 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. [13] The Los Angeles County and City established paramedic programs following the passage of The Wedsworth-Townsend Act in 1970. Other cities and states passed their own paramedic bills, leading to the formation of services across the US. Many other countries also followed suit, and paramedic units 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. 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.

Public notability

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 1977, 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 1977, 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. Ron Stewart, the show's medical director, was instrumental in organizing emergency health services in southern California earlier in his career during the 1970s, in the paramedic program in Pittsburgh, and had a substantial role in the founding of the paramedic programs in Toronto and Nova Scotia, Canada.

Evolution and growth

Throughout the 1970s and 1980s, 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".

Bicycle paramedics in Los Angeles indicate the changing nature of the job. Bicycle Paramedics.JPG
Bicycle paramedics in Los Angeles indicate the changing nature of the job.

The training, knowledge-base, and skill sets of both paramedics and emergency medical technicians (EMTs) were typically determined by local medical directors based primarily on the perceived needs of the community along with affordability. 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. Within the UK training is a three-year course equivalent to a bachelor's degree. Comparisons have been made between Paramedics and nurses; with nurses now requiring degree entry (BSc) the knowledge deficit is large between the two fields. 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 and Care Professions Council (HCPC) 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 inadequately outside of hospitals, 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 ALS). 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. In 2010, the American Board of Emergency Medicine created a medical subspecialty for physicians who work in emergency medical services. [14]

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. 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.

Canada

Firefighters assist while paramedics from the Toronto Paramedic Services load a patient into an ambulance. TorontoEMSactionshot.JPG
Firefighters assist while paramedics from the Toronto Paramedic Services load a patient into an ambulance.

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. The province of Ontario announced that by September 2021, the entry level primary care paramedic post-secondary program would be enhanced from a two-year diploma to a three-year advanced diploma in primary care paramedicine. Resultantly, advanced care paramedics in Ontario will require a minimum of four years of post-secondary education and critical care paramedics will require five years of post-secondary education.

Israel

In Israel, paramedics are trained in either of the following ways: a three-year degree in Emergency Medicine (B.EMS), a year and three months IDF training, or MADA training. Paramedics manage and provide medical guidelines in mass casualty incidents. They operate in MED evac and ambulances. They are legalized under the 1976 Doctors Ordinance (Decree). In a 2016 study at the Ben Gurion University of the Negev it was found that 73% of trained paramedics stop working within a five-year period, and 93% stop treating within 10 years. [15]

United Kingdom

In the United Kingdom, ambulances were originally municipal services after the end of World War II. Training was frequently conducted internally, although national levels of coordination led to more standardization of staff training. Ambulance services were merged into county-level agencies in 1974, and then into regional agencies in 2006. The regional ambulance services, most often trusts, are under the authority of the National Health Service and there is now a significant standardization of training and skills.

The UK model has three levels of ambulance staff. In increasing order of clinical skill these are: emergency care assistants, ambulance technicians and paramedics.

The original route to becoming a paramedic was to join an NHS ambulance service and work towards the position from non-emergency patient transport roles through to the emergency division as a Qualified Ambulance Man/Woman and after qualifying those who wanted to increase their knowledge and skills joined the Association of Emergency Medical Technicians. This was an organisation run by members to promote and train Paramedics. The AEMT was supported by BASICS and large numbers of hospital doctors. Training took place at various locations in members off duty time and at their expense. Trainees followed a wide academic curriculum which led to a written exam. If successful they became Associates and entered the clinical phase of training. Attending hospitals they were trained in all the practical skills. The final examination was designed to put as much pressure on the candidate as possible. The hospital consultant would sign to say that he was happy for a passing candidate to treat their family.

In the 1970s some ambulance service training departments started offering advanced skill training under the direction of Peter Baskett (Consultant Anaesthetist at Frenchay Hospital, Bristol) and Douglas Chamberlain (Consultant Cardiologist in Brighton). This was the inception of the paramedic service in the UK, and subsequently was developed across Europe. In 1986 the NHSTA introduced the certificate in Extended Ambulance Aid. Existing AEMT Paramedics were forced to sit a conversion examination. The curriculum for the new qualification was substantially smaller cutting out a lot of anatomy and physiology as well as pharmacology and obstetrics. In November 1986 the examinations took place with the first certificates issued alphabetically. The candidate with highest score received certificate 177 and was the only Paramedic at Huntingdon. Training was introduced the following year but due to costs the time was kept to a minimum. The AEMT folded in the 1990s as the training offered was no longer recognised by the ambulance services. Equipment owned by the branches was given to hospitals.

The NHS Training Authority, NHSTA, (which became the NHS Training Directorate and then the NHS Training Division, which in turn became the Institute of Health and Care Development. The institute was acquired by the Edexcel examination board in 1998, and Edexcel was acquired by Pearson in 2004. Pearson continued to operate the IHCD 'brand' until 2016. This 'in-house' paramedic training was a modular programme, usually between 10 and 12 weeks, followed by time spent in a hospital emergency department, coronary care centre and operating theatre, assisting the anaesthetist and performing airway management techniques such as endotracheal intubation. Completion of the course allowed the paramedic to register with the Council for Professions Supplementary to Medicine (CPSM), which was superseded by the Health and Care Professions Council (HCPC), a regulatory body. It is worth noting that this route also took around 3 years if undertaken as quickly as possible. After the non emergency training, initially an 8-week clinical technician course was undertaken, with 750 mentored hours. Staff usually had to be a qualified technician for 2 years before applying for paramedic training noted above, a further 750 hours mentored had to be undertaken to complete the paramedic course to practice and demonstrate the skills learnt during the hospital placements and residential course.

Prior to regulation and closure of the title, the term "paramedic" was used by a variety of people with varying levels of ability. Paramedics could apply to register via a grandfather scheme which ended in 2002.

However, university qualifications are expected for paramedics, with the entry level being an Honours Bachelor of Science degree in Pre-Hospital Care or Paramedic Science. As the title "Paramedic" is legally protected, those utilising must be registered with the Health and Care Professions Council (HCPC), [16] and in order to qualify for registration you must meet the standards for registration, which include having a degree obtained through an approved course. [17] [18]

It is common for paramedics to have master's degrees in Advanced practice or Paramedic practice and is indeed a requisite for paramedic prescribing.

Paramedics work in various settings including NHS and Independent Ambulance Providers, Air Ambulances, Emergency Departments and other alternative settings. Some 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. This is a fully autonomous role, and such senior paramedics are now working in hospitals, community teams such as rapid response teams, and also in increasing numbers in general practice, where their role includes acute presentations, complex chronic care and end of life management. They work as part of the allied health professional team including Doctors, Nurses, physician Associates, Physiotherapists, Associate Physicians, Health Care Assistant and Clinical Pharmacists. Paramedic Practitioners also undertake examinations modelled upon the MRCGP (a combination of applied knowledge exams, clinical skills and work place based assessment) in order to use the title "specialist". There are also now a growing number of these advanced paramedics who are independent and supplementary prescribers. There are also 'Critical Care Paramedics' who specialise in acute emergency incidents. In 2018, the UK government changed legislation allowing Paramedics to independently prescribe, [19] which will open new pathways to Paramedics to progress into. This came into force on 1 April 2018, but did not immediately affect practice as guidance was still being written. [20]

United States

In the United States, the minimum standards for paramedic training is considered vocational, but many colleges offer paramedic associate degree or bachelor's degree options. Paramedic education programs typically follow the U.S. NHTSA EMS Curriculum, DOT or National Registry of EMTs. [21] While many regionally accredited community colleges offer paramedic programs and two-year associate degrees, a handful of universities also offer a four-year bachelor's degree component. [22] The national standard course minimum requires didactic and clinical hours for a paramedic program of 1,500 or more hours of classroom training and 500+ clinical hours to be accredited and nationally recognized. [23] [24] Calendar length typically varies from 12 months to upwards of two years, excluding degree options, EMT training, work experience, and prerequisites. It is required to be a certified Emergency Medical Technician prior to starting paramedic training. [25] Entry requirements vary, but many paramedic programs also have prerequisites such as one year required work experience as an emergency medical technician, or anatomy and physiology courses from an accredited college or university. Paramedics in some states must attend up to 50+ hours of ongoing education, plus maintain Pediatric Advanced Life Support and Advanced Cardiac Life Support. National Registry requires 70 + hours to maintain its certification or one may re-certify through completing the written computer based adaptive testing again (between 90 and 120 questions) every two years.

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. [26] The early technicians with limited training, performing a small and specific set of procedures, has become a role beginning to require a foundation degree in countries such as Australia, South Africa, the UK, and increasingly in Canada and parts of the U.S. such as Oregon, where a degree is required for entry level practice. [27]

Ukraine

As a part of Emergency Medicine Reform in 2017 Ministry of Healthcare introduced two specialties — "paramedic" and "emergency medical technician". [28] A paramedic is a person with at least junior bachelor degree in "Healthcare" field. For a person with basic nine-year school education, the term of training is four years (junior bachelor's degree equivalent); with 11 years of schooling - two years for junior bachelor or 3–4 years for bachelor's degrees. [28]

Structure of employment

Firefighter paramedics assist a simulated burn victim during a US Navy mass casualty drill. US Navy 070119-N-4049C-024 Firefighter Paramedics William Strickland and Steven Ames assist a simulated burn victim during a mass casualty drill at Naval Branch Health Clinic Mayport.jpg
Firefighter paramedics assist a simulated burn victim during a US Navy mass casualty drill.

Paramedics are employed by a variety of different organizations, and the services they provide 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 emergency medical service for their area, although this employer could 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. In Washington, firefighters have been offered free paramedic training. [29] There are also many paramedics who volunteer for backcountry or wilderness rescue teams, and small town rescue squads. In the specific case of an ambulance service being maintained by a fire department, paramedics and EMTs may be required to maintain firefighting and rescue skills as well as medical skills, and vice versa. In some instances, such as Los Angeles County, a fire department may provide emergency medical services, but as a rapid response or rescue unit rather than a transport ambulance.

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 distinct service, linked to the fire service, or contracted out to a third party.

Scope of Practice

Common skills

While there are varying degrees of training and expectations around the world, a set of skills practiced by paramedics in the pre-hospital setting commonly includes: [30]

Emergency Pharmacology

Paramedics carry and administer a wide array of emergency medications. The specific medications they are permitted to administer vary widely, based on local standards of care and protocols. 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:

A paramedic preparing an intravenous infusion for a patient Patient Care.jpg
A paramedic preparing an intravenous infusion for a patient

Skills by certification level

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 issueBasic Life Support (BLS) Provider

Emergency Medical Technician - United States (120-200 hrs. education)

Emergency Medical Responder - Canada (80 hrs. education)

Intermediate Life Support (ILS) Provider

Advanced EMT - United States (3-6 mo. education)

Paramedic - Australia (Bachelor's Degree)

Primary Care Paramedic - Canada (2-3 yr. education)

Advanced Life Support (ALS) Provider

Paramedic - United States (1-2 yr. education)

Intensive Care Paramedic - Australia (Master's Degree)

Advanced Care Paramedic - Canada (4 yr. education)

Airway managementAssessment, manual repositioning, oropharyngeal and nasopharyngeal airway adjuncts, manual removal of obstructions, suctioningUse of supraglottic airway devices such as the I-Gel or King-LT airway Endotracheal intubation, cricothyrotomy (surgical airway), delayed and rapid sequence induction (in some jurisdictions), use of magill forceps, airway suctioning.
BreathingAssessment (rate, effort, symmetry, skin color), obstructed airway maneuver, supplemental oxygen administration by nasal cannula, rebreathing and non-rebreathing mask, positive pressure ventilation by bag valve mask (BVM). CPAP Decompression of tension pneumothorax by needle or incision thoracostomy, BIPAP, use of mechanical transport ventilators.
CirculationControl of hemorrhage using direct and indirect pressure, tourniquets, wound packing and hemostatic agents, basic shock management and hypothermia prevention, pelvic binding.IV fluid resuscitation. 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), pericardiocentesis.
Cardiac arrest Cardiopulmonary resuscitation, basic airway adjuncts, suctioning, BVM ventilation, semi-automatic defibrillation.Expanded resuscitation skills including supraglottic airway placement, monitoring of capnography, administration of epinephrine/adrenaline (in some jurisdictions).Expanded drug therapy options (epinephrine, anti-arrhythmics), ECG interpretation, manual defibrillation, intubation, ultrasound.
Cardiac MonitoringPlacement of ECGs electrodes and ability to transmit to hospital for interpretation.Twelve lead ECG monitoring and interpretationAdvanced ECG interpretation
Drug administrationOral, nebulized, and intramuscular injection of a limited list of drugslimited list of drugs for intramuscular, subcutaneous, intravenous injection (bolus), intravenous drip, and transdermal. Infusion pump and intraosseous access.
Drug types permittedLow-risk and immediate requirements, e.g., aspirin and nitroglycerin (chest pain), oral glucose and glucagon (hypoglycemia), epinephrine (anaphylaxis or respiratory failure), albuterol (asthma), and naloxone (narcotic overdose).Intravenous fluids, dextrose infusion (hypoglycemia), and symptom relief medications such as ondansetron (nausea), dipenhydramine (pruritus), and non-narcotic pain management (nitrous oxide, methoxyflurane, ketorolac, acetaminophen).Significantly expanded drug list, most commonly narcotics, sedatives, vasopressors, antidotes, neuromuscular blockers, and advanced cardiac and respiratory medications. In some jurisdictions, paramedics may also permitted to administer blood products, tranexamic acid, and antibiotics.
Patient assessmentBasic physical assessment, vital signs, history taking, lung auscultation, pulse oximetry.More detailed physical assessment and history, capnography.Advanced assessment, 4 and 12-lead ECG interpretation, ultrasound, [36] point-of-care blood chemistry interpretation (glucose, lactate, hemoglobin, troponin).
Other procedures.Splinting of bone fractures, uncomplicated and complicated childbirth.Wound closure (butterfly stitches, suturing), fracture/dislocation reduction, umbilical venous access, chemically facilitated extrication, emergency surgical procedures such as escharotomy or field amputation (in some jurisdictions).

Medicolegal authority

The medicolegal framework for paramedics is highly dependent on the overall structure of emergency medical services in the territory where they are working.

Paramedics load an injured woman into an air ambulance after a head-on collision in the Kawartha Lakes region of Ontario, Canada. Medical evacuation after car accident Kawartha Lakes Ontario.jpg
Paramedics load an injured woman into an air ambulance after a head-on collision in the Kawartha Lakes region of Ontario, Canada.

In many localities, paramedics operate as a direct extension of a physician medical director and practice as an extension of the medical director's license. In the United States, a physician delegates authority under an individual state's Medical Practice Act. This gives a paramedic the ability to practice within limited scope of practice in law, along with state DOH guidelines and medical control oversight. The authority to practice in this manner is granted in the form of standing orders (protocols) (off-line medical control) and 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.

In places where paramedics are recognised 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 and Care 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 or advanced paramedic, which may allow them to administer a wider range of drugs and use a wider range of clinical skills.

In some areas, paramedics are only permitted to practice many advanced skills while assisting a physician who is physically present, except for immediately life-threatening emergencies.

In entertainment

See also

Paramedics by country
Related fields
Other

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<span class="mw-page-title-main">Emergency medical services</span> Services providing acute medical care

Emergency medical services (EMS), also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilisation for serious illness and injuries and transport to definitive care. They may also be known as a first aid squad, FAST squad, emergency squad, ambulance squad, ambulance corps, life squad or by other initialisms such as EMAS or EMARS.

<span class="mw-page-title-main">Emergency medical technician</span> Health care provider of emergency medical services

An emergency medical technician (EMT), also known as an ambulance technician, is a health professional that provides emergency medical services. EMTs are most commonly found working in ambulances. In English-speaking countries, paramedics are a separate profession that has additional educational requirements, qualifications, and scope of practice.

A medical director is a physician who provides guidance and leadership on the use of medicine in a healthcare organization. These include the emergency medical services, hospital departments, blood banks, clinical teaching services and others. A medical director devises the protocols and guidelines for the clinical staff and evaluates them while they are in use.

<span class="mw-page-title-main">Paramedics in Canada</span> Overview of paramedics in Canada

A paramedic is a healthcare professional, providing pre-hospital assessment and medical care to people with acute illnesses or injuries. In Canada, the title paramedic generally refers to those who work on land ambulances or air ambulances providing paramedic services. Paramedics are increasingly being utilized in hospitals, emergency rooms, clinics and community health care services by providing care in collaboration with registered nurses, registered/licensed practical nurses and registered respiratory therapists.

<span class="mw-page-title-main">Paramedics in Germany</span> Overview of paramedics in Germany

Paramedics in Germany are the main providers of emergency care in emergency medical services in Germany. There exist two professional levels regulated by federal law, the Rettungsassistent and the Notfallsanitäter.

<span class="mw-page-title-main">Paramedics in the United States</span> Overview of paramedics in the United States of America

In the United States, the paramedic is a professional whose primary focus is to provide advanced emergency medical care for critical and emergency patients who access Emergency Medical Services (EMS). This individual possesses the complex knowledge and skills necessary to provide patient care and transportation. Paramedics function as part of a comprehensive EMS response, under medical oversight. Paramedics perform interventions with the basic and advanced equipment typically found on an ambulance. The paramedic is a link from the scene into the health care system. One of the eligibility requirements for state certification or licensure requires successful completion of a nationally accredited Paramedic program at the certificate or associate degree level. Each state varies in requirements to practice as a paramedic, and not all states require licensure.

Wilderness Emergency Medical Technician (WEMT) is an emergency medical technician that is better equipped than other licensed healthcare providers, who typically function almost exclusively in urban environments, to better stabilize, assess, treat, and protect patients in remote and austere environments until definitive medical care is reached. Despite the term, WEMT training is available and geared not just to the EMT, but also the paramedic, prehospital registered nurse, registered nurse, physician assistant, and medical doctor. After all, without an understanding of the applicable gear, skills, and knowledge needed to best function in wilderness environments, including a fundamental understanding of the related medical issues more commonly faced, even an advanced provider may often become little more than a first responder when called upon in such an emergency. WEMT training and certification is similar in scope to wilderness advanced life support (WALS) or other courses for advanced providers such as AWLS, WUMP, WMPP, and RMAP. Unlike more conventional emergency medicine training, wilderness emergency medicine places a greater emphasis on long-term patient care in the backcountry where conventional hospital care can be many hours, even days, away to reach.

<span class="mw-page-title-main">Center for Emergency Medicine of Western Pennsylvania</span>

The Center for Emergency Medicine of Western Pennsylvania is a multi-hospital consortium based in Pittsburgh, Pennsylvania. It is claimed to be one of the world's premiere centers of Emergency Medicine and EMS development. It currently ranks sixth for residencies in emergency medicine by reputation.

<span class="mw-page-title-main">Louisville Metro EMS</span>

Louisville Metro Emergency Medical Services is the primary provider of pre-hospital life support and emergency care within Louisville-Jefferson County, Kentucky. LMEMS is a governmental department that averages 90,000 calls for service, both emergency and non-emergency, each year.

<span class="mw-page-title-main">Emergency medical services in the United States</span> Overview of emergency medical services in the United States

In the United States, emergency medical services (EMS) provide out-of-hospital acute medical care and/or transport to definitive care for those in need. They are regulated at the most basic level by the National Highway Traffic Safety Administration, which sets the minimum standards that all states' EMS providers must meet, and regulated more strictly by individual state governments, which often require higher standards from the services they oversee.

<span class="mw-page-title-main">Emergency medical personnel in the United Kingdom</span> People engaged in the provision of emergency medical services

Emergency medical personnel in the United Kingdom are people engaged in the provision of emergency medical services. This includes paramedics, emergency medical technicians and emergency care assistants. 'Paramedic' is a protected title, strictly regulated by the Health and Care Professions Council, although there is tendency for the public to use this term when referring to any member of ambulance staff.

In the US, paramedicine is the physician-directed practice of medicine, often viewed as the intersection of health care, public health, and public safety. While discussed for many years, the concept of paramedicine was first formally described in the EMS Agenda for the Future. Paramedicine represents an expansion of the traditional notion of emergency medical services as simply an emergency response system. Paramedicine is the totality of the roles and responsibilities of individuals trained and credentialed as EMS practitioners. These practitioners have been referred to as various levels of Emergency Medical Technician (EMTs). In the United States paramedics represent the highest practitioner level in this domain. Additional practitioner levels in this domain within the U.S. include Emergency Medical Responders (EMRs), Emergency Medical Technicians (EMTs) and Advanced Emergency Medical Technicians (AEMTs).

Advanced emergency medical technicians (AEMT) are providers of prehospital emergency medical services in the United States. A transition to this level of training from the emergency medical technician-intermediate (EMT-I), which have somewhat less training, began in 2013 and has been implemented by most states at this point. The AEMT is not intended to deliver definitive medical care in most cases, but rather to augment prehospital critical care and provide rapid on-scene treatment. AEMTs are most usually employed in ambulance services, working in conjunction with EMTs and paramedics, however are also commonly found in fire departments and law enforcement agencies as non-transporting first responders. Ambulances operating at the AEMT level of care are commonplace in rural areas, and occasionally found in larger cities as part of a tiered-response system, but are overall much less common than EMT- and paramedic-level ambulances. The AEMT provides a low-cost, high-benefit option to provide advanced-level care when the paramedic level of care is not feasible. The AEMT is authorized to provide limited advanced life support, which is beyond the scope of an EMT.

In the United States, the licensing of prehospital emergency medical providers (EMTs) and oversight of emergency medical services are governed at the state level. Each state is free to add or subtract levels as each state sees fit. Therefore, due to differing needs and system development paths, the levels, education requirements, and scope of practice of prehospital providers varies from state to state. Even though primary management and regulation of prehospital providers is at the state level, the federal government does have a model scope of practice including minimum skills for EMRs, EMTs, Advanced EMTs and Paramedics set through the National Highway Traffic Safety Administration (NHTSA).

<span class="mw-page-title-main">Emergency medical responder</span> Person who provides out-of-hospital care in medical emergencies

Emergency medical responders are people who are specially trained to provide out-of-hospital care in medical emergencies. There are many different types of emergency medical responders, each with different levels of training, ranging from first aid and basic life support. Emergency medical responders have a very limited scope of practice and have the least amount of comprehensive education, clinical experience or clinical skills of emergency medical services (EMS) personnel. The EMR program is not intended to replace the roles of emergency medical technicians or paramedics and their wide range of specialties. Emergency medical responders typically assist in rural regions providing basic life support where pre-hospital health professionals are not available due to limited resources or infrastructure.

Emergency medical services in New Zealand are provided by the Order of St John, except in the Greater Wellington region where Wellington Free Ambulance provides these services. Both have a history of long service to their communities, St John since 1885 and Free beginning in 1927, traditionally having a volunteer base, however the vast majority of response work is undertaken by paid career Paramedics. Strategic leadership of the sector is provided by NASO which is a unit within the Ministry of Health responsible for coordinating the purchasing and funding of services on behalf of the Ministry and the Accident Compensation Corporation.

Emergency medical services in Sri Lanka is being established using a public/private system aimed at the provision of emergency ambulance service, including emergency care and transportation to hospitals. The Pre-Hospital Care Committee is part of the Trauma Secretariat of the Sri Lanka Ministry of Healthcare and Nutrition and was established following the 2004 tsunami. The goal of the Pre-Hospital Care Sub-Committee is “During this generation and continuing for future generations, everyone in Sri Lanka will have access to trained pre-hospital medical personnel, ambulances are available to transport the sick and injured safely to hospitals, complications from harmful or inadequate pre-hospital care is eliminated so physician and nursing personnel at hospitals are delivered patients they are able to professionally treat and rehabilitate back to society as contributing citizens.” Pre-Hospital care is an essential, core component of trauma system.

The College of Paramedics is the recognised professional body for paramedics in the United Kingdom. The role of the College is to promote and develop the paramedic profession across England, Scotland, Wales and Northern Ireland.

Emergency medicine reform in Ukraine has been part of Ukraine's healthcare reform program since its launch in 2016. Managed by the Ministry of Healthcare of Ukraine, the program is meant to improve the quality and speed of Ukraine's emergency medical care.

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Further reading