Paramedics in the United States
Encyclopedia
accredited Paramedic program at the certificate or associates degree level.
History
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. Around 1966 in a published report entitled "Accidental Death and Disability: The Neglected Disease of Modern Society", (known in EMS trade as the White PaperWhite paper
A white paper is an authoritative report or guide that helps solve a problem. White papers are used to educate readers and help people make decisions, and are often requested and used in politics, policy, business, and technical fields. In commercial use, the term has also come to refer to...
) medical researchers began to reveal, to their astonishment, that soldiers who were seriously wounded on the battlefields of Vietnam
Vietnam
Vietnam – sometimes spelled Viet Nam , officially the Socialist Republic of Vietnam – is the easternmost country on the Indochina Peninsula in Southeast Asia. It is bordered by China to the north, Laos to the northwest, Cambodia to the southwest, and the South China Sea –...
had a better survival rate than those individuals who were seriously injured in motor vehicle accidents on California
California
California is a state located on the West Coast of the United States. It is by far the most populous U.S. state, and the third-largest by land area...
freeways. Early research attributed these differences in outcome to a number of factors, including comprehensive trauma
Physical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
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
Fluid replacement
Fluid replacement or fluid resuscitation is the medical practice of replenishing bodily fluid lost through sweating, bleeding, fluid shifts or other pathologic processes. Fluids can be replaced via oral administration , intravenous administration, rectally, or hypodermoclysis, the direct injection...
and airway management
Airway management
In cardiopulmonary resuscitation, anaesthesia, emergency medicine, intensive care medicine and first aid, airway management is the process of ensuring that:# there is an open pathway between a patient’s lungs and the outside world, and...
, which allowed the victim to survive the journey to definitive care.
As a result of this publication, a series of grand experiments began in the United States. Pittsburgh's Freedom House
Freedom House
Freedom House is an international non-governmental organization based in Washington, D.C. that conducts research and advocacy on democracy, political freedom and human rights...
paramedics are credited as the first emergency medical technician
Emergency medical technician
Emergency Medical Technician or Ambulance Technician are terms used in some countries to denote a healthcare provider of emergency medical services...
(EMT) trainees in America. Pittsburgh's Peter Safar
Peter Safar
Peter Safar was an Austrian physician of Czech descent. He is credited with pioneering cardiopulmonary resuscitation.- Early life :...
is referred to as the father of CPR. In 1967, he began training unemployed African-American men in what later became Freedom House Ambulance Service, the first paramedic squadron in the United States. 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
Medic One
The Seattle & King County Emergency Medical Services System is a fire-based two-tier response system providing prehospital basic and advanced life support services....
program at Harborview Medical Center
Harborview Medical Center
Harborview Medical Center, located on Seattle's First Hill, is a public hospital in King County, Washington and is managed by UW Medicine.-Overview:...
and the University of Washington
University of Washington
University of Washington is a public research university, founded in 1861 in Seattle, Washington, United States. The UW is the largest university in the Northwest and the oldest public university on the West Coast. The university has three campuses, with its largest campus in the University...
Medical Center, started by Leonard Cobb, M.D., began training firefighters in CPR in 1970. 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. In Los Angeles, a pilot paramedic program, involving firefighters from only two county fire department rescue squads initially, began under the direction of Ronald Stewart, M.D.
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, the father of trauma medicine, devised the concept of integrated emergency care, designing the first civilian Medevac
MEDEVAC
Medical evacuation, often termed Medevac or Medivac, is the timely and efficient movement and en route care provided by medical personnel to the wounded being evacuated from the battlefield or to injured patients being evacuated from the scene of an accident to receiving medical facilities using...
helicopter program and campaigning for a statewide EMS system. Other communities that were early participants in the development of paramedicine included Jacksonville, Florida
Jacksonville, Florida
Jacksonville is the largest city in the U.S. state of Florida in terms of both population and land area, and the largest city by area in the contiguous United States. It is the county seat of Duval County, with which the city government consolidated in 1968...
, Pittsburgh, Pennsylvania
Pittsburgh, Pennsylvania
Pittsburgh is the second-largest city in the US Commonwealth of Pennsylvania and the county seat of Allegheny County. Regionally, it anchors the largest urban area of Appalachia and the Ohio River Valley, and nationally, it is the 22nd-largest urban area in the United States...
(in an expanded program), and Seattle, Washington
Seattle, Washington
Seattle is the county seat of King County, Washington. With 608,660 residents as of the 2010 Census, Seattle is the largest city in the Northwestern United States. The Seattle metropolitan area of about 3.4 million inhabitants is the 15th largest metropolitan area in the country...
(in an expanded program). In 1972 the first civilian emergency medical helicopter transport service, Flight for Life
Flight For Life
Flight for Life is a prehospital care service with many bases of operation across the United States. Flight for Life is primarily known for its emergency medical helicopter transport, but also operates a fleet of land vehicles and fixed wing aircraft for the transport of critically ill patients to...
opened in Denver, Colorado. Emergency medical helicopter
Helicopter
A helicopter is a type of rotorcraft in which lift and thrust are supplied by one or more engine-driven rotors. This allows the helicopter to take off and land vertically, to hover, and to fly forwards, backwards, and laterally...
s 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
Intensive care medicine
Intensive-care medicine or critical-care medicine is a branch of medicine concerned with the diagnosis and management of life threatening conditions requiring sophisticated organ support and invasive monitoring.- Overview :...
air transport (inter-hospital) in addition to emergency medical services (pre-hospital).
In a curious example of 'life imitating art' a television producer
Television producer
The primary role of a television Producer is to allow all aspects of video production, ranging from show idea development and cast hiring to shoot supervision and fact-checking...
, working for producer Jack Webb
Jack Webb
John Randolph "Jack" Webb , also known by the pseudonym John Randolph, was an American actor, television producer, director and screenwriter, who is most famous for his role as Sergeant Joe Friday in the radio and television series Dragnet...
, of Dragnet
Dragnet (series)
Dragnet is a radio and television crime drama about the cases of a dedicated Los Angeles police detective, Sergeant Joe Friday, and his partners...
and Adam-12
Adam-12
Adam-12 was a television police drama which followed two police officers of the Los Angeles Police Department, Pete Malloy and Jim Reed, as they patrolled the streets of Los Angeles in their patrol unit, 1-Adam-12. Created by Jack Webb who is known for creating Dragnet, the series captured a...
fame, happened to be 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!
Emergency!
Emergency! is an American television series that combines the medical drama and action-adventure genres. It was produced by Mark VII Limited and distributed by Universal Studios...
television series, which ran from 1972–1977, 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 exactly 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
James O. Page
James O. Page, JD , was recognized as a leading authority on United States emergency medical services . Page served in the Los Angeles County Fire Department for 16 years rising to the rank of Battalion Chief. In 1973 he was appointed as the first director of North Carolina's statewide EMS system...
, then a Battalion Chief responsible for the Los Angeles County Fire Department
Los Angeles County Fire Department
The Los Angeles County Fire Department , serves unincorporated parts of Los Angeles County, as well as 58 cities and towns that choose to have the county provide fire and EMS services, including La Habra. It should not be confused with the Los Angeles City Fire Department, which serves the city of...
'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.
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, Bretyllium 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
Evidence-based medicine
Evidence-based medicine or evidence-based practice aims to apply the best available evidence gained from the scientific method to clinical decision making. It seeks to assess the strength of evidence of the risks and benefits of treatments and diagnostic tests...
; 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. Such changes affected everything from simple procedures, such as CPR, to changes in drug protocols and other advanced procedures. 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.
Education
The education and skills required of paramedics vary by state. The U.S. National Highway Traffic Safety AdministrationNational Highway Traffic Safety Administration
The National Highway Traffic Safety Administration is an agency of the Executive Branch of the U.S. government, part of the Department of Transportation...
(NHTSA) designs and specifies a National Standard Curriculum
for EMT training. Most paramedic education and certifying programs require that a student is at a minimum educated and trained to the National Standard Curriculum for a particular skill level. The National Registry of Emergency Medical Technicians
National Registry of Emergency Medical Technicians
The National Registry of Emergency Medical Technicians is a US certification agency covering prehospital medical providers.- History :NREMT was established in 1970 in response to President Lyndon Johnson's Committee on Highway Traffic Safety recommended a national certifying agency for Emergency...
(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.
Paramedic education programs can be as short as 8 months or as long as 4 years. An Associate's degree program is 2 years, often administered through a community college. Degree programs are an option, with two year Associate's degree programs being most common, although four year Bachelor's degree programs exist. 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 the prospective paramedic hopes to practice. Regardless of education, all students must meet the same state requirements to take the certification exams, including the National Registry exams. 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
American Heart Association
The American Heart Association is a non-profit organization in the United States that fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke. It is headquartered in Dallas, Texas...
.
Credentialling and oversight
In the U.S., the community college training model remains the most common, although university-based paramedic education models continue to evolve. These variations in both educational approaches and standards led to tremendous differences from one location to another, and at its worst, created a situation 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) 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 a EMT obtains certification through NREMT (NREMT-P, NREMT-I, NREMT-B), this is accepted by 40 of the 50 states in the United States. 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 AdministrationNational Highway Traffic Safety Administration
The National Highway Traffic Safety Administration is an agency of the Executive Branch of the U.S. government, part of the Department of Transportation...
(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. 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. Medical oversight became driven more by chart review or rounds, than by step by step control during each call.
Examples of procedures performed by paramedics
Just as with the use of medications, the other medical procedures and procedures permitted to paramedics varies broadly from one jurisdiction to another. It is not possible to provide a single set of procedures or medications that universally represents all paramedics in the United States. The lists below, while not universal, are fairly representative.Procedures by certification level
Although there is a great deal of variation in what EMTs and paramedics are trained and permitted to do from region to region, some skills performed by EMTs and paramedics include:| Treatment issue | EMT-B and EMT-I skills | Some EMT-I and all EMT-P skills | Advanced paramedic skills |
|---|---|---|---|
| Airway management | Manual and repositioning, Oro- and nasopharyngeal airway adjuncts, manual removal of obstructions, suctioning, and in some states Advanced Airway Management (combitube Combitube The Combitube is a blind insertion airway device often used in the pre-hospital, emergency setting. It is designed to facilitate the tracheal intubation of a patient in respiratory distress. It consists of a cuffed, double-lumen tube that is inserted into a the patient's airway facilitating... and King airways) |
Endotracheal intubation (in some cases, naso as well), advanced airway management, ETT, LMA, ETOA, and combitube Combitube The Combitube is a blind insertion airway device often used in the pre-hospital, emergency setting. It is designed to facilitate the tracheal intubation of a patient in respiratory distress. It consists of a cuffed, double-lumen tube that is inserted into a the patient's airway facilitating... , deep suctioning, use of Magill forceps |
Rapid sequence induction Rapid sequence induction Rapid Sequence Induction is a medical procedure involving the expeditious induction of general anesthesia and subsequent intubation of the trachea. RSI is generally used in an emergency setting or for patients who have an increased risk of aspirating stomach contents into the lungs... , surgical airways (including needle cricothyrotomy and others) |
| Breathing | Initial assessment (rate, effort, symmetry, skin color), obstructed airway maneuver, passive oxygen Oxygen Oxygen is the element with atomic number 8 and represented by the symbol O. Its name derives from the Greek roots ὀξύς and -γενής , because at the time of naming, it was mistakenly thought that all acids required oxygen in their composition... administration by nasal canula, rebreathing and non-rebreathing mask, active oxygen administration by Bag-Valve-Mask (BVM Bag valve mask A bag valve mask is a hand-held device used to provide positive pressure ventilation to a patient who is not breathing or who is breathing inadequately. The device is a normal part of a resuscitation kit for trained professionals, such as ambulance crew... ) device. |
Pulse oximetry Pulse oximetry Pulse oximetry is a non-invasive method allowing the monitoring of the oxygenation of a patient's hemoglobin.A sensor is placed on a thin part of the patient's body, usually a fingertip or earlobe, or in the case of an infant, across a foot.... , active oxygen administration by endotracheal tube or other device using BVM |
Use of mechanical transport ventilators, active oxygen administration by surgical airway, decompression of chest cavity using needle/valve device (needle thoracostomy) |
| Circulation | Assessment of pulse (rate, rhythm, volume), blood pressure Blood pressure Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies... and capillary refill, patient positioning to enhance circulation, recognition and control of hemorrhage of all types using direct and indirect pressure and tourniquets |
Ability to interpret assessment findings in terms of levels of perfusion Perfusion In physiology, perfusion is the process of nutritive delivery of arterial blood to a capillary bed in the biological tissue. The word is derived from the French verb "perfuser" meaning to "pour over or through."... , intravenous fluid replacement, vasoconstricting drugs |
intravenous plasma volume expanders, blood transfusion Blood transfusion Blood transfusion is the process of receiving blood products into one's circulation intravenously. Transfusions are used in a variety of medical conditions to replace lost components of the blood... , intraosseous (IO) cannulation (placement of needle into marrow space of a large bone), central venous access (central venous catheter by way of external jugular or subclavian) |
| Cardiac arrest Cardiac arrest Cardiac arrest, is the cessation of normal circulation of the blood due to failure of the heart to contract effectively... |
Cardiopulmonary resuscitation Cardiopulmonary resuscitation Cardiopulmonary resuscitation is an emergency procedure which is performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest. It is indicated in those who are unresponsive... , airway management, manual ventilation with BVM, automatic external defibrillator |
Dynamic resuscitation including intubation, drug administration (includes anti-arrhythmics), ECG interpretation (may be limited to Lead II) Semi-automatic or manual defibrillator | Expanded drug therapy options, ECG interpretation (12 Lead), manual defibrillator, synchronized mechanical or chemical cardioversion Cardioversion Cardioversion is a medical procedure by which an abnormally fast heart rate or cardiac arrhythmia is converted to a normal rhythm, using electricity or drugs. Synchronized electrical cardioversion uses a therapeutic dose of electric current to the heart, at a specific moment in the cardiac cycle... , external pacing of the heart |
| Cardiac Monitoring | Cardiac monitoring Cardiac monitoring The phrase cardiac monitoring generally refers to continuous monitoring with electrocardiography with assessment of the patients condition relative to their cardiac rhythm. It is different from hemodynamic monitoring, which monitors the pressure and flow of blood within the circulatory system. The... and interpretation of ECGs Electrocardiogram Electrocardiography is a transthoracic interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body... |
12-lead ECG monitoring and interpretation | 18-lead ECG monitoring and interpretation |
| Drug administration | Limited oral, limited aerosol, limited injection (usually IM) | Intramuscular, subcutaneous, intraosseous, intravenous injection (bolus Bolus -Medicine:* Bolus , the administration of a drug, medication or other substance in the form of a single, large dose* Bolus , a tissue equivalent substance used in radiation therapy... ), IV drip |
Per Endotracheal Tube (ETT), via retcal route (pr), per infusion pump Infusion pump An infusion pump infuses fluids, medication or nutrients into a patient's circulatory system. It is generally used intravenously, although subcutaneous, arterial and epidural infusions are occasionally used.... |
| Drug types permitted | Low-risk/immediate requirements, such as aspirin Aspirin Aspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. It was discovered by Arthur Eichengrun, a chemist with the German company Bayer... (chest pain), nitroglycerin (chest pain), oral glucose Glucose Glucose is a simple sugar and an important carbohydrate in biology. Cells use it as the primary source of energy and a metabolic intermediate... (diabetes), glucagon Glucagon Glucagon, a hormone secreted by the pancreas, raises blood glucose levels. Its effect is opposite that of insulin, which lowers blood glucose levels. The pancreas releases glucagon when blood sugar levels fall too low. Glucagon causes the liver to convert stored glycogen into glucose, which is... (diabetes), epinephrine Epinephrine Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines... (Allergic Reaction), or ventolin Ventolin Ventolin may refer to:* Salbutamol, bronchodilator medication marketed under the brand name Ventolin amongst others.* "Ventolin" , a song and single by Richard D James/Aphex Twin, named after the medicine... (Asthma). Some jurisdictions also permit naloxone Naloxone Naloxone is an opioid antagonist drug developed by Sankyo in the 1960s. Naloxone is a drug used to counter the effects of opiate overdose, for example heroin or morphine overdose. Naloxone is specifically used to counteract life-threatening depression of the central nervous system and respiratory... (Narcotic Overdose), nitrous oxide Nitrous oxide Nitrous oxide, commonly known as laughing gas or sweet air, is a chemical compound with the formula . It is an oxide of nitrogen. At room temperature, it is a colorless non-flammable gas, with a slightly sweet odor and taste. It is used in surgery and dentistry for its anesthetic and analgesic... (for pain); there is considerable variation by jurisdiction. |
Considerable expansion of permitted drugs, but still typically limited to about 20, including analgesics (narcotic Narcotic The term narcotic originally referred medically to any psychoactive compound with any sleep-inducing properties. In the United States of America it has since become associated with opioids, commonly morphine and heroin and their derivatives, such as hydrocodone. The term is, today, imprecisely... or otherwise) (for pain), antiarrhythmics (irregularities in heartbeat), major cardiac resuscitation drugs, bronchodilators (for breathing), vasoconstrictors (to improve circulation), sedatives |
Dramatically expanded (up to 60+) drug list. In some jurisdictions advanced levels of paramedics are permitted to administer any drug, as long as they are familiar with it. In some jurisdictions certain types of advanced paramedics have limited authority to prescribe Medical prescription A prescription is a health-care program implemented by a physician or other medical practitioner in the form of instructions that govern the plan of care for an individual patient. Prescriptions may include orders to be performed by a patient, caretaker, nurse, pharmacist or other therapist.... medications. |
| 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 Capnography Capnography is the monitoring of the concentration or partial pressure of carbon dioxide in the respiratory gases. Its main development has been as a monitoring tool for use during anaesthesia and intensive care. It is usually presented as a graph of expiratory plotted against time, or, less... , pulse oximetry Pulse oximetry Pulse oximetry is a non-invasive method allowing the monitoring of the oxygenation of a patient's hemoglobin.A sensor is placed on a thin part of the patient's body, usually a fingertip or earlobe, or in the case of an infant, across a foot.... |
Interpretation of lab results, interpretation of chest x-rays, interpretation of cranial CT scan, limited diagnosis Diagnosis Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships... (e.g. rule out fracture using Ottawa Ankle Rules) and now ultrasonography |
| Wound management | Assessment, control of bleeding Bleeding Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system... , application of pressure dressings and other types of dressings |
Wound cleansing, wound closure with Steri-strips, suturing |
Skills common to all EMTs and paramedics
- Spinal injury management, including immobilization and safe transport.
- Fracture management, including assessment, splinting, traction splints where appropriate.
- ObstetricsObstetricsObstetrics is the medical specialty dealing with the care of all women's reproductive tracts and their children during pregnancy , childbirth and the postnatal period...
, assessment, assisting with uncomplicated childbirth, recognition of and procedures for obstetrical emergencies, such as breech presentation, cord presentation, placental abruptionPlacental abruptionPlacental abruption is a complication of pregnancy, wherein the placental lining has separated from the uterus of the mother. It is the most common pathological cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth...
. - Management of burns, including classification, estimate of surface area, recognition of more serious burns, treatment.
- Assessment and evaluation of general incident scene safety.
- Effective verbal and written reporting skills (Charting).
- Routine medical equipment maintenance procedures.
- Routine radio operating procedures.
- TriageTriageTriage or ) is the process of determining the priority of patients' treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning to separate,...
of patients in a mass casualty incident. - Emergency vehicle operation.
Medications administered
Paramedics in most jurisdictions administer a variety of emergency medications; the individual medications vary widely, based on physician medical director preference, local standard of care, and law. These drugs may include Adenocard (Adenosine), which slow the heart for a short period of time, and Atropine, which speeds a heartbeat that is too slow. The list may include sympathomimetics like dopamineDopamine
Dopamine is a catecholamine neurotransmitter present in a wide variety of animals, including both vertebrates and invertebrates. In the brain, this substituted phenethylamine functions as a neurotransmitter, activating the five known types of dopamine receptors—D1, D2, D3, D4, and D5—and their...
for severe hypotension
Hypotension
In physiology and medicine, hypotension is abnormally low blood pressure, especially in the arteries of the systemic circulation. It is best understood as a physiologic state, rather than a disease. It is often associated with shock, though not necessarily indicative of it. Hypotension is the...
(low blood pressure) and cardiogenic shock. Diabetics often benefit from the fact that paramedics are able to give D50W (Dextrose 50%) to treat hypoglycemia (low blood sugar). They can treat crisis and anxiety conditions. Some advanced paramedics may also be permitted to perform rapid sequence induction; a rapid way of obtaining an advanced airway with the use of paralytics and sedatives, using such medications as Versed
Midazolam
Midazolam is a short-acting drug in the benzodiazepine class developed by Hoffmann-La Roche in the 1970s. The drug is used for treatment of acute seizures, moderate to severe insomnia, and for inducing sedation and amnesia before medical procedures. It possesses profoundly potent anxiolytic,...
, Ativan, or Etomidate
Etomidate
Etomidate is a short acting intravenous anaesthetic agent used for the induction of general anaesthesia and for sedation for short procedures such as reduction of dislocated joints, tracheal intubation and cardioversion...
, and paralytics such as succinylcholine, rocuronium
Rocuronium
Rocuronium is an aminosteroid non-depolarizing neuromuscular blocker or muscle relaxant used in modern anaesthesia, to facilitate endotracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation.Introduced in 1994, rocuronium has...
, or vecuronium
Vecuronium
Vecuronium is a muscle relaxant in the category of non-depolarizing blocking agents. Vecuronium bromide is indicated as an adjunct to general anesthesia, to facilitate endotracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation...
. Paramedics in some jurisdictions may also be permitted to sedate combative patients using antipsychotics like Haldol or Geodon. The use of medications for treating respiratory conditions such as, albuterol
Salbutamol
Salbutamol or albuterol is a short-acting β2-adrenergic receptor agonist used for the relief of bronchospasm in conditions such as asthma and chronic obstructive pulmonary disease. It is marketed as Ventolin among other brand names....
, atrovent
Ipratropium
Ipratropium bromide is an anticholinergic drug used for the treatment of chronic obstructive pulmonary disease and acute asthma. It blocks the muscarinic acetylcholine receptors in the smooth muscles of the bronchi in the lungs, opening the bronchi...
, and methylprednisolone
Methylprednisolone
Methylprednisolone is a synthetic glucocorticoid or corticosteroid drug. It is marketed in the USA and Canada under the brand names Medrol and Solu-Medrol. It is also available as a generic drug....
is common. Paramedics may also be permitted to administer medications such as those that relieve pain or decrease nausea and vomiting. Nitroglycerin, baby aspirin, and morphine sulfate may be administered for chest pain. Paramedics may also use other medications and antiarrhythmics like amiodarone
Amiodarone
Amiodarone is an antiarrhythmic agent used for various types of tachyarrhythmias , both ventricular and supraventricular arrhythmias. Discovered in 1961, it was not approved for use in the United States until 1985...
to treat cardiac arrhythmias such as ventricular tachycardia
Ventricular tachycardia
Ventricular tachycardia is a tachycardia, or fast heart rhythm, that originates in one of the ventricles of the heart...
and ventricular fibrillation
Ventricular fibrillation
Ventricular fibrillation is a condition in which there is uncoordinated contraction of the cardiac muscle of the ventricles in the heart, making them quiver rather than contract properly. Ventricular fibrillation is a medical emergency and most commonly identified arrythmia in cardiac arrest...
not responding to defibrillation. Paramedics also treat for severe pain, i.e. burns or fractures, with narcotics like morphine sulfate, pethidine
Pethidine
Pethidine or meperidine Pethidine (INN) or meperidine (USAN) Pethidine (INN) or meperidine (USAN) (commonly referred to as Demerol but also referred to as: isonipecaine; lidol; pethanol; piridosal; Algil; Alodan; Centralgin; Dispadol; Dolantin; Mialgin (in Indonesia); Petidin Dolargan (in Poland);...
, fentanyl and in some jurisdictions, ketorolac
Ketorolac
Ketorolac or ketorolac tromethamine is a non-steroidal anti-inflammatory drug in the family of heterocyclic acetic acid derivative, often used as an analgesic...
. This list is not representative of all jurisdictions, and EMS jurisdictions may vary greatly in what is permitted. Some jurisdictions may not permit administration of certain classes of drugs, or may use drugs other than the ones listed for the same purposes. For an accurate description of permitted drugs or procedures in a given location, it is necessary to contact that jurisdiction directly.
Employment
Paramedics are employed by various public and private emergency serviceEmergency service
Emergency services are organizations which ensure public safety and health by addressing different emergencies. Some agencies exist solely for addressing certain types of emergencies whilst others deal with ad hoc emergencies as part of their normal responsibilities...
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
Ambulance
An ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury, and in some instances will also provide out of hospital medical care to the patient...
, rescue vehicle, helicopter, fixed-wing aircraft, motorcycle, or fire suppression apparatus
Fire apparatus
A fire apparatus, fire engine, fire truck, or fire appliance is a vehicle designed to assist in fighting fires by transporting firefighters to the scene and providing them with access to the fire, along with water or other equipment...
.
Phlebotomy
Phlebotomy is the process of making an incision in a vein.It is associated with the following concepts:* Venipuncture, the practice of collecting venous blood samples* The main practice of a phlebotomist, an individual trained to draw blood...
, blood bank
Blood bank
A blood bank is a cache or bank of blood or blood components, gathered as a result of blood donation, stored and preserved for later use in blood transfusion. The term "blood bank" typically refers to a division of a hospital laboratory where the storage of blood product occurs and where proper...
s, research labs, educational fields, law enforcement and hospitals.
Aside from their traditional roles, paramedics may also participate in one of many specialty arenas:
- Critical care transporters move patients by ground ambulance or aircraft between medical treatment facilies. This may be done to allow a patient to receive a higher level of care in a more specialized facility. Registered Nurses with training in critical care medicineCritical Care MedicineCritical Care Medicine is a peer-reviewed medical journal in the field of intensive care medicine. It is the official publication of the Society of Critical Care Medicine, and is published by Lippincott Williams & Wilkins. The editor-in-chief is Joseph E. Parrillo....
may work side-by-side with paramedics in these settings. Paramedics participating in this role generally also provide care not traditionally administered by Paramedics who respond to 911 calls. Examples of this are blood transfusions, intra-aortic balloon pumpIntra-aortic balloon pumpThe Intra-aortic balloon pump ' is a mechanical device that increases myocardial oxygen perfusion while at the same time increasing cardiac output. Increasing cardiac output increases coronary blood flow and therefore myocardial oxygen delivery...
s, and mechanical ventilators. - Tactical paramedics work on law enforcement teams (SWATSWATA SWAT team is an elite tactical unit in various national law enforcement departments. They are trained to perform high-risk operations that fall outside of the abilities of regular officers...
). These medics, usually from the EMS agency in the area, are commissioned and trained to be tactical operators in law enforcement, in addition to paramedic duties. Advanced medical personnel perform dual roles as operator and medic on the teams. Such an officer is immediately available to deliver advanced emergency care to other injured officers, suspects, innocent victims and bystanders. The advantage to having dual role paramedics is that medical care is provided almost immediately. - In-Hospital paramedics are increasingly employed in hospital emergency departmentEmergency departmentAn emergency department , also known as accident & emergency , emergency room , emergency ward , or casualty department is a medical treatment facility specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance...
s and intensive care unitIntensive Care Unitthumb|220px|ICU roomAn intensive-care unit , critical-care unit , intensive-therapy unit/intensive-treatment unit is a specialized department in a hospital that provides intensive-care medicine...
s. With their specialized training, in emergent situations, paramedics are generally accustomed to practicing with greater latitude and autonomy. This training emphasizes discretionary decisions and treatment without mandatory physician consultation.