In the United States, the paramedic is an allied health professional whose primary focus is to provide advanced emergency medical care for 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 physician medical direction. Paramedics often serve in a prehospital role, responding to Public safety answering point (9-1-1) calls in an ambulance. The paramedic serves as the initial entry point into the health care system. A standard requirement for state licensure involves successful completion of a nationally accredited Paramedic program at the certificate or associate degree level. [1]
Prior to 1970, ambulances were staffed with advanced first-aid level responders who were frequently referred to as "ambulance attendants." There was little regulation or standardized training for those staffing these early emergency response vehicles or the required equipment carried inside. Around 1966 in a published report entitled "Accidental Death and Disability: The Neglected Disease of Modern Society", [2] (known in EMS trade as the White Paper) medical researchers began to reveal, to their astonishment, that soldiers who were seriously wounded on the battlefields of Vietnam had a better survival rate than those individuals who were seriously injured in motor vehicle accidents on California freeways. Early research attributed these differences in outcome to a number of factors, including comprehensive trauma care, rapid transport to designated trauma facilities, and a new type of medical corpsman; one who was trained to perform certain critical advanced medical procedures such as fluid replacement and airway management, which allowed the victim to survive the journey to definitive care.
During the 1960's, a Los Angeles cardiologist named Walter S. Graf became concerned about the lack of actual medical care being given to coronary patients during emergency transportation to a hospital. In 1969, while serving as president of the Los Angeles Chapter of the American Heart Association, he created a "mobile critical care unit", consisting of a Chevy van, a registered nurse, and a portable defibrillator. [3] The same year his patient Kenneth Hahn, a member of the Los Angeles County Board of Supervisors, persuaded the Supervisors to approve a pilot program to train county firefighters as "Mobile Intensive Care Paramedics". A change in state law was necessary to allow personnel other than doctors and nurses to render emergency medical care. Hahn recruited two state legislators who wrote the Wedworth-Townsend Paramedic Act of 1970, signed into law by Governor Ronald Reagan on July 15, 1970, despite opposition from doctors, nurses, and attorneys. Paramedic training began the next month at the Freeman Memorial Hospital under Graf's direction. [4] It was the first nationally accredited paramedic training program in the United States. [5]
Other communities in the United States were also experimenting with advanced emergency medical care. Pittsburgh's branch of Freedom House paramedics are credited as the first emergency medical technician (EMT) trainees in the United States. Pittsburgh's Peter Safar is referred to as the father of CPR. [6] In 1967, he began training unemployed African-American men in what later became Freedom House Ambulance Service, [7] [8] the first paramedic squadron in the United States. [9] [10] Almost simultaneously, and completely independent from one another, experimental programs began in three U.S. centers; Miami, Florida; Seattle, Washington; and Los Angeles, California. Each was aimed at determining the effectiveness of using firefighters to perform many of these same advanced medical skills in the pre-hospital setting in the civilian world. Many in the senior administration of the fire departments were initially quite opposed to this concept of 'firemen giving needles', and actively resisted and attempted to cancel pilot programs more than once. 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. [11] Dr. Eugene Nagel trained city of Miami firefighters as the first U.S. paramedics to use invasive techniques and portable defibrillators with telemetry in 1967. [12] Dr. Jonathan Wasserberger helped actualize the teaching curriculum associated with this innovative training in 1973. [13] [14] [15]
Elsewhere, the novel approach to pre-hospital care was also evolving. Portland's Leonard Rose, M.D., in cooperation with Buck Ambulance Service, instituted a cardiac training program and began training other paramedics. Baltimore's R. Adams Cowley, [16] 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. Other communities that were early participants in the development of paramedicine included Jacksonville, Florida, Pittsburgh, Pennsylvania (in an expanded program), and Seattle, Washington (in an expanded program). In 1972 the first civilian emergency medical helicopter transport service, Flight for Life opened in Denver, Colorado. [17] Emergency medical helicopters were soon put into service elsewhere in 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).
A television producer, working for producer Jack Webb, [18] of Dragnet and Adam-12 fame, was in Los Angeles' UCLA Harbor Medical Center, doing background research for a proposed new TV show about doctors, when he happened to encounter these 'firemen who spoke like doctors and worked with them'. This novel idea would eventually evolve into the Emergency! television series, which ran from 1972 to 1977, portraying the exploits of a new group called 'paramedics'. The show captured the imagination of emergency services personnel, the medical community, and the general public. When the show first aired in 1972, there were only 6 full-fledged paramedic units operating in 3 pilot programs (Miami, Los Angeles, Seattle) in the whole of the United States. No one had ever heard the term 'paramedic'; indeed, it is reported that one of the show's actors was initially concerned that the 'para' part of the term might involve jumping out of airplanes! By the time the program ended production in 1977, there were paramedics operating in every state. The show's technical advisor was a pioneer of paramedicine, James O. Page, [19] then a Battalion Chief responsible for the Los Angeles County Fire Department 'paramedic' program, but who would go on to help establish other paramedic programs in the U.S., and to become the founding publisher of the Journal of Emergency Medical Services. [20]
Throughout the 1970s and 1980s, the field continued to evolve, although in large measure, on a local level. In the broader scheme of things the term 'ambulance service' was replaced by 'emergency medical service' to reflect the change from a transportation system to a system that provides actual medical care. The training, knowledge base, and skill sets of both paramedics and emergency medical technicians (both competed for the job title, and 'EMT-Paramedic' was a common compromise) were typically determined by what local medical directors were comfortable with, what it was felt that the community needed, and what could actually be afforded. There were also tremendous local differences 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 ultimately even to universities. During the evolution of paramedicine, a great deal of both curriculum and skill set was in a state of constant flux. Permissible skills evolved in many cases at the local level, and were based upon the preferences of physician advisers and medical directors. Treatments would go in and out of fashion, and sometimes, back in again. The use of certain drugs, Bretylium for example, illustrate this. In some respects, the development seemed almost faddish. Technologies also evolved and changed, and as medical equipment manufacturers quickly learned, the pre-hospital environment was not the same as the hospital environment; equipment standards that worked fine in hospitals could not cope well with the less controlled pre-hospital environment.
Physicians began to take more interest in paramedics from a research perspective as well. By about 1990, most of the 'trendiness' in pre-hospital emergency care had begun to disappear, and was replaced by outcome-based research and evidence-based medicine; [21] the gold standard for the rest of medicine. This research began to drive the evolution of the practice of both paramedics and the emergency physicians who oversaw their work; changes to procedures and protocols began to occur only after significant outcome-based research demonstrated their need. Paramedics became increasingly accountable for their errors as well, and these too led to changes in procedure. [22] Such changes affected everything from simple procedures, such as CPR, to changes in drug protocols and other advanced procedures. [23] As the profession of paramedic grew, some of its members actually went on to become not just research participants, but researchers in their own right, with their own projects and journal publications.
The education and skills required of paramedics vary by state. The U.S. National Highway Traffic Safety Administration (NHTSA) designs and specifies a National Standard Curriculum [24] 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. [25] 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. [26]
Paramedic education programs can be as short as six months or as long as four years. An associate degree program is two years, often administered through a community college. Degree programs are an option, with two-year associate degree programs being most common, although four-year bachelor's degree programs exist. In contrast to Commonwealth countries such as Canada, the United Kingdom, Australia and New Zealand, generally the minimum education is a two- to three-year degree at an accredited college or university for the entry-level paramedic, with four-year or even graduate degrees becoming the preferred credential in such jurisdictions. Many paramedic programs in the United States are through adult career and technical schools that provide a certificate of completion upon completion of the program. All programs must meet the current national standard curriculum. The institutions offering such training vary greatly across the country in terms of programs and requirements, and each must be examined by the prospective student in terms of both content and requirements where they hope to practice. [27]
Regardless of education, all students must meet the same state requirements to take the certification exams, including the National Registry exams which consist of a psychomotor skills practical examination and a Computer Based Testing (CBT). In addition, most locales require that paramedics attend ongoing refresher courses and continuing medical education to maintain their license or certification. In addition to state and national registry certifications, most paramedics are required to be certified in pediatric advanced life support, pediatric prehospital care or pediatric emergencies for the prehospital provider, prehospital trauma life support; international trauma life support, and advanced cardiac life support. These additional requirements have education and certification from organizations such as the American Heart Association.
In the U.S., the community college training model remains the most common, although some university-based paramedic education models exist. These variations in both educational approaches and standards has led to tremendous differences from one location to another. There may be situations in which a group of people with 120 hours of training, and another group (in another jurisdiction) with university degrees, were both calling themselves 'paramedics'. There were some efforts made to resolve these discrepancies. The National Association of Emergency Medical Technicians (NAEMT) along with National Registry of Emergency Medical Technicians (NREMT) [28] attempted to create a national standard by means of a common licensing examination, but to this day, this has never been universally accepted by U.S. States, and issues of licensing reciprocity for paramedics continue, although if an EMT obtains certification through NREMT (NREMT-P, NREMT-I, NREMT-B), this is accepted by 40 of the 50 states in the United States. [29] This confusion was further complicated by the introduction of complex systems of gradation of certification, reflecting levels of training and skill, but these too were, for the most part, purely local. To clarify, at least at a national level, the National Highway Traffic Safety Administration (NHTSA), which is the federal organization with authority to administer the EMS system, defines the various titles given to prehospital medical workers based on the level of care they provide. They are EMT-P (Paramedic), EMT-I (Intermediate), EMT-B (Basic), and First Responders. While providers at all levels are considered emergency medical technicians, the term "paramedic" is most properly used in the United States to refer only to those providers who are EMT-P's. Apart from this distinction, the only truly common trend that would evolve was the relatively universal acceptance of the term 'emergency medical technician' being used to denote a lower level of training and skill than a 'paramedic'.
Changes in procedures also included the manner in which the work of paramedics was overseen and managed. In the earliest days of the field, medical control and oversight was direct and immediate, with paramedics calling into a local hospital and receiving orders for every individual procedure or drug. [30] This still occurs in some jurisdictions, but is becoming very rare. As physicians began to build a bond of trust with paramedics, and experience in working with them, their confidence levels also rose. Increasingly, in many jurisdictions day-to-day operations moved from direct and immediate medical control to pre-written protocols or 'standing orders', with the paramedic typically only calling in for direction after the options in the standing orders had been exhausted. [31] Medical oversight became driven more by chart review or rounds, than by step by step control during each call.
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In the United States there are no federal guidelines for the scope of practice for any level of EMS provider. In the field, paramedics follow a set of pre-approved procedures and interventions for particular scenarios. For example, all fifty states allow for the administration of some form of anti-convulsive. [32] In the state of Massachusetts a paramedic may administer the anti-convulsant, midazolam, up to a maximum of 6 mg . [33] While in Maine paramedics are allowed to administer midazolam in upwards of 10 mg boluses. [34] These pre-approved procedures are known as standing orders. Standing orders cannot surpass a provider's scope of practice. Scopes of practice represent the degree to which providers are trained. [35]
The following is derived NHTSA's "National EMS Scope of Practice model". Without federal mandate, each state's office of emergency medical services may alter their respective standing orders. The purpose of the model is to provide a guide toward standardization in patient care that both improves patient outcomes but allows for reciprocity between states. [36] Prior to certification as a paramedic, candidates must be a certified EMT. Traditionally, a paramedic is allowed to perform all skills an EMT may perform. [37]
Below are some of the key skills and procedures expected of a paramedic in the United States. [38]
One of the primary differences between emergency medical technicians and paramedics includes the breadth and number of medications paramedic ambulances typically carry. Due to the variation between each state EMS office it would be cumbersome and unrealistic to list each and every single medication paramedics carry across the United States. [43] Instead, different medications are carried to serve similar patient-care scenarios. Most services carry medications like albuterol or ipratropium to alleviate bronchospasm during an acute asthma attack. [44] They carry cardiac medications to reverse deadly heart rhythms like amiodarone and lidocaine. [45] They can also use medications like atropine, adenosine and different types of beta-blockers as heart rate controls. [46] [47] Paramedics may also utilize a number of other medications for analgesia, such as antiemetics and anti-convulsants. [48] In the setting of inter-facility transfers providers may continue the administration of other medications that are not typically carried in the field (Heparin, Blood products, Potassium).
The aforementioned skills and medications are often standing orders in state protocols. The expectations and responsibilities of providers varies across state lines. There are instances where special waivers granted by states allowing paramedic services to go beyond their protocols. [49] For example, some paramedics in New Hampshire may be allowed to perform a surgical cricothyrotomy, medics in Virginia are allowed to use ultrasound as a diagnostic technique and paramedics in Arizona are allowed to perform rapid-sequence intubation utilizing paralytic and sedating medication to completely control a patient's airway. [50] [51] [52]
Paramedics are employed by various public and private emergency service providers. These include private ambulance services, fire departments, public safety or police departments, hospitals, law enforcement agencies, the military, and municipal EMS agencies in addition to and independent from police or fire departments, also known as a 'third service'. Paramedics may respond to medical incidents in an ambulance, rescue vehicle, helicopter, fixed-wing aircraft, motorcycle, bicycles, 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. [53]
Aside from their traditional roles, paramedics may also participate in one of many specialty arenas:
The salary of a paramedic in the US varies. The average is $63,000, with the top 10% earning over $117,000, considerably less than the salaries of paramedics in Canada. Factors such as education and location of the paramedic's practice influence the salary. Paramedic supervisors and managers may make between $60,000- $140,000, depending on location.
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.
An emergency medical technician is a medical professional that provides emergency medical services. EMTs are most commonly found serving on ambulances and in fire departments in the US and Canada, as full-time and some part-time departments require their firefighters to be EMT certified.
A paramedic is a healthcare professional trained in the medical model, whose main role has historically been to respond to emergency calls for medical help outside of a hospital. Paramedics work as part of the emergency medical services (EMS), most often in ambulances. They also have roles in emergency medicine, primary care, transfer medicine and remote/offshore medicine. The scope of practice of a paramedic varies between countries, but generally includes autonomous decision making around the emergency care of patients.
A certified first responder is a person who has completed a course and received certification in providing pre-hospital care for medical emergencies. Certified individuals should have received much more instruction than someone who is trained in basic first aid and cardiopulmonary resuscitation (CPR) but they are not necessarily a substitute for more advanced emergency medical care rendered by emergency medical technicians and paramedics. First responders typically provide advanced first aid level care, CPR, and automated external defibrillator (AED) usage. The term "certified first responder" is not to be confused with "first responder", which is a generic term referring to the first medically trained responder to arrive on scene and medically trained telecommunication operators who provide pre-arrival medical instructions as trained Emergency Medical Dispatchers (EMD). Many police officers and firefighters are required to receive training as certified first responders. Advanced medical care is typically provided by EMS, although some police officers and firefighters also train to become emergency medical technicians or paramedics.
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.
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.
Advanced Emergency Medical Technician - Critical Care (AEMT-CC) is a former Emergency Medical Services (EMS) certification that was unique to New York. The curriculum for AEMT-CC's in New York was similar to that of the national standard EMT-I/99 but with a broader scope of practice. EMT-CCs are fully classified as Advanced Life Support (ALS) providers within New York and are trained in advanced airway management, including intubation, IV fluid administration, cardiac monitoring, cardiac pacing, and both synchronized and unsynchronized cardioversion, and medication usage/administration in adult and pediatric patients.
An wilderness emergency medical technician is an emergency medical technician that is better equipped than other licensed healthcare providers, who typically function almost exclusively in wilderness environments, to better stabilize, assess, treat, and protect patients in remote and austere environments until definitive medical care is reached. Despite the term, wilderness emergency medical technician training is available and geared not just to the emergency medical technician, 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.
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.
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.
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.
In the United States, 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 US, paramedics represent the highest practitioner level in this domain. Additional practitioner levels in this domain within the US include emergency medical responders (EMRs), emergency medical technicians (EMTs) and advanced emergency medical technicians (AEMTs).
The National Registry of Emergency Medical Technicians (NREMT) is a US based, non-profit certification organization for pre-hospital emergency medical providers that exists to ensure that all EMS clinicians have the knowledge and skills required for competent practice.
An advanced emergency medical technician (AEMT) is a provider of emergency medical services in the United States. A transition to this level of training from the emergency medical technician-intermediate, which have somewhat less training, began in 2013 and has been implemented by most states. AEMTs are 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 usually employed in ambulance services, working in conjunction with EMTs and paramedics; however they 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.
Emergency Medical Technician is the entry level of Emergency Medical Technician in the United States.
In the United States, the licensing of prehospital emergency medical providers 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).
Emergency Medical Responders (EMRs) are people who are specially trained to provide out-of-hospital care in medical emergencies, typically before the arrival of an ambulance. Specifically used, an emergency medical responder is an EMS certification level used to describe a level of EMS provider below that of an emergency medical technician and paramedic. However, the EMR is not intended to replace the roles of such providers and their wide range of specialties.
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.
Intermediate Life Support (ILS) is a level of training undertaken in order to provide emergency medical care outside medical facilities. ILS is classed as mid-level emergency medical care provided by trained first responders who receive more training than basic life support providers, but less than advanced life support providers. Intermediate Life Support is also known as Limited Advanced Life Support (LALS), Immediate Life Support, or Intermediate Advanced Life Support (IALS).