during a training exercise]]
A paramedic is a medical professional specialising in emergency medical care, which is delivered outside of a clinical environment such as a hospital. Paramedics primarily work as part of the emergency medical services, providing advanced levels of care for acute medical problems and trauma care, followed, where appropriate, by transfer to definitive care.
The majority of paramedics are field based in ambulances, ambulance cars or on specialist units such as cycle response, although some may undertake hospital-based roles, such as the treatment of minor injuries.
The term paramedic is widely used to describe ambulance and emergency medical personnel of all training levels and experience, but in many countries, including the United States, United Kingdom and Germany, the use of the term 'paramedic', or its local translation, is restricted by law. This restriction means that only people meeting a set level of qualifications, skills and experience may use the title, as is the case with other health professions, such as doctors and nurses. In these cases, the country usually has a registration scheme where an official body maintains a list of those people legally qualified to use the title.
Other countries do not have the legal restrictions on the use of paramedic as a job title, and it is legitimately used to refer to all ambulance crew members. This is the case in countries such as Canada and South Africa, with training grades then distinguished by the terms such as primary, intermediate or advanced (e.g. Primary Care Paramedic).
Etymology
The term paramedic comes from para- (auxiliary) and medical, and means "related to medicine in an auxiliary capacity". The military term "paramedic", meaning "parachuting medical corpsmen", came later.
History of paramedicine
Early history
Throughout the evolution of paramedicine, 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 tasked with 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, suturing wounds, completing amputations, and not through training, but by default. This trend would continue throughout the
Crusades, with the Knights Hospitallers of the
Order of St. John of Jerusalem, known throughout the
Commonwealth of Nations today as
St. John Ambulance, filling a similar function.
Early civilian ambulance services
While communities had organized to deal with the care and transportation of the sick and dying as far back as the
plague in London, England (1598, 1665), such arrangements were typically temporary. In time, however, such arrangements began to formalize and become permanent. During the
American Civil War,
Jonathan Letterman had devised a system of
mobile
field hospitals employing the principles of
triage were first instituted, with some veterans began to attempt to apply what had they had seen on the battlefield to their own communities, through the creation of volunteer life-saving squads and ambulance corps.
The development of formalised ambulance services was decided at local levels and this led to services being provided by diverse operators such as the local hospital, police, fire brigade or even local undertakers (having the only transport in town in which one could lie down).
Prior to First World War, there were a handful of motorized ambulances but following the proving of motor ambulances on the battlefield, the concept spread rapidly to civilian systems.
In most cases, these ambulances were operated by drivers and attendants with little or no medical training, and it was some time until formal training started to appear in some units. Early examples include members of the Toronto Police Ambulance Service receiving a mandatory five days of training, conducted by St. John, as early as 1889 .
In terms of advanced skills, it is known that, once again, the military led the way. During the Second World War and the Korean War, battlefield 'medics' were administering painkilling narcotics by injection, as emergency procedures, and 'pharmacists' mates' on warships without physicians were permitted to do even more. Korea also marked the first widespread use of helicopters to evacuate the wounded from forward positions to medical units, coining the phrase 'medevac'. These innovations would not find their way into the civilian sphere for nearly twenty more years.
Pre-hospital emergency care
By the early 1960s experiments in improving care had begun in some civilian centres. The first such experiment involved the provision of pre-hospital cardiac care by physicians in Belfast, Northern Ireland, in 1966 . This was repeated in Toronto, Canada in 1968, using a single ambulance called Cardiac One, staffed by a regular ambulance crew, plus a hospital intern, who was tasked with performing the advanced procedures. While both of these experiments had certain levels of success, technology had not yet reached the required level (the Toronto 'portable'
defibrillator/heart monitor was powered by lead-acid car batteries and weighed nearly ). The required telemetry and miniaturization technologies already existed in the military, and particularly in the space program, but it would take several more years before they found their way 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 in some cases still operate, in the United Kingdom, Europe, and Latin America.
In the United States in 1966 a report called "Accidental Death and Disability: The Neglected Disease of Modern Society", (sometimes known as the White Paper) was published, in which it was presented 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.
Key factors in this difference were given as being 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.
As a direct result, a series of pilots were started across the United States, which then rapidly transitioned to being operating units, the first being in Los Angeles with the passage of the Wedsworth-Townsend Act, where the fire department set up a permanent 'paramedic' unit. This was followed by other cities and states passing their own paramedic bills, starting to form services nationwide.
The public discovers paramedicine
In a curious example of 'life imitating art', television producer
Robert A. Cinader, working for producer
Jack Webb of
Dragnet and
Adam-12 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! 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 exactly six paramedic units operating in three pilot programs 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, then a Battalion Chief responsible for the 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 (JEMS).
Evolution and growth
Throughout the 1970s and 80s, the field continued to evolve, with a shift in emphasis from transport to treatment both on scene and en-route. This led to some services changing nomlencature from 'ambulance services' to '
emergency medical services'
The training, knowledge base, and skill sets of both paramedics and emergency medical technicians 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 to university level education. This has following the progression of other health professions such as nursing, which has progressed from on the job training to a university level qualification.
These variations in both educational approaches and standards have led to large differences in qualication between locations, both within individual countries and from country to country.
This has led to many countries passing laws to protect the title of 'paramedic' (or its local equivalent) from use by anyone except those qualified and experienced to a defined standard. This usually means that paramedics must be registered with the appropriate body in their country. For instance, in the United Kingdom, all paramedics must by registered with the Health Professions Council in order to call themselves a paramedic. In the United States, a similar system is operated by the National Registry of Emergency Medical Technicians (NREMT), but this is only accepted by 40 of the 50 states.
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 which 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; 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. Such changes affected everything from simple procedures, such as CPR, to changes in drug protocols. As the profession of paramedicine 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.
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.
Evolution in other jurisdictions
In other places, the evolution of paramedicine occurred somewhat differently. In Canada, for example, there was an early, but unsuccessful attempt to introduce paramedicine. In 1972, a pilot paramedic training program occurred at
Queen's University, located in
Kingston, Ontario. The program, intended to upgrade the mandatory 160 hours of training then required for 'ambulance attendants', was found to be too costly and premature. While the program operated for two years and produced a number of graduates, it would be more than a decade before the legislative authority for them to practice was put into place. The program then moved in another direction, providing 1,400 hours of training at the community college level, prior to commencing employment. This change was made mandatory in 1977, with formal certification examinations being introduced for the first time in 1978. Similar, but not identical, programs occurred at roughly the same time in the Province of Alberta, and in British Columbia, through its Justice Institute. Other Canadian provinces gradually followed, but with their own education and certification requirements. Advanced Care Paramedics were not introduced until 1984, when Toronto trained its first group internally, and the process continued to spread across the country. The current model in Ontario calls for a two year community college based program, including both hospital and field clinical components, prior to designation as a Primary Care Paramedic, although this is gradually evolving in the direction of a university degree-based program. Some services, such as
Toronto EMS, continue to train paramedics internally (indeed, Toronto EMS is accredited in its own right by the Canadian Medical Association as an Advanced Care Paramedic training academy).
In the United Kingdom, ambulance services became largely municipal services, with some exceptions, shortly after the end of World War Two. Training was frequently conducted internally, although national levels of coordination led to better standardization of staff training. All public ambulance services are currently operated by regional entities, most often 'trusts', under the authority of the National Health Service. Tremendous standardization of training and permitted skills has also occurred. The UK model utilizes, two levels of ambulance staff. The first of these is 'Ambulance Technician'. This role is not a paramedic, but more closely corresponds to the EMT role in the United States. Most services train these individuals internally, using a common curriculum. The second role is that of 'Paramedic'. These are practitioners of advanced life support skills, similar to U.S. paramedics. Initially, many of these individuals were trained internally by the services that employed them, with the step to Paramedic being a logical career path progression for an experienced Ambulance Technician. Increasingly, this trend has moved toward training in the University system, with the entry level for Paramedics being an Honours Bachelor of Science degree in Pre-Hospital or Paramedic Care. Some British Paramedics have been further elevated, into the role of Paramedic Practitioner, a role that practices independently in the pre-hospital environment, in a capacity similar to that of a nurse practitioner, but with more of an acute care orientation. Some Paramedic Practitioners in the U.K. hold M.Sc. degrees.
The growth of a new profession
Today, the field of para medicine continues to grow and evolve into a formal profession in its own right, complete with its own standards and body of knowledge. What began as a concept of simple 'technicians' with a couple of weeks of training, performing procedures that they didn't fully understand, has evolved into a career that in many cases (U.K., South Africa, Australia and increasingly the U.S. and Canada), requires a university education, and which is, in some locations actually evolving into a second tier medical practitioner. In many places, the practice of paramedics began as an extension of the supervising physician's license to practice medicine. As such, they were absolutely subject to every condition that the physician placed on their practice. More recently, however, paramedics in both the U.K. and some Canadian provinces have been granted the legal status of self-regulated health professions. When this occurs, the individual paramedics are registered by The Health Professions Council, created by legislation to protect the public. This body sets the standards of education, the standards of proficiency and deals with complaints regarding individual practitioners, and consults the government with respect to legislation, policy, and regulations. Paramedics are learning to govern themselves and have an active Professional Body called the College of Paramedics; the true measure of a profession. In the U.S., paramedics are subject to regulation by individual states, and the degree and type of regulation, as well as paramedic participation in that process, varies from state to state.
Places of work
Paramedics are employed by a variety of different organizations, and the services provided by paramedics may occur under differing organizational structures, depending on the part of the world. In the United States, a paramedic can be employed by government agencies such as the Parks Service or the Coast Guard. They may also be employed as part of a public
hospital system; in some cases working inside the hospital. They are most commonly employed as part of a municipal
Emergency Medical Service, which may be free-standing "Third Service" (municipal department operating independently of other emergency services) option, or a part of some other public safety agency, such as a fire, police, or the health department. Paramedics may also be employed by private companies, some of which may have contractual emergency service provision commitments to local municipalities, corporations, mines, air ambulances, or racetracks or entertainment venues. Paramedics may also work on a volunteer basis, receiving no monetary compensation for their services (i.e. Volunteer Rescue Squad / Volunteer Fire Department and community response units). Another newly emerging field in the world of Emergency Medical Service is the role of Tactical Medics. Their responsibility lies with providing care to injured and wounded SWAT officers in austere and extremely hazardous environments while under enemy fire. Highly specialized training is required for certification as Emergency Medical Technician - Tactical. This career field is open to both basic and advanced level providers.
In the UK, paramedics are typically employed by ambulance services, as a part of the National Health Service Trust system. An NHS Trust is, in effect, a type of public sector corporation, and most NHS health services, including both primary care and hospitals, are organized in this fashion. Service organization occurs regionally, with Ambulance Service Trusts typically covering several local Counties, and with 12 such Trusts currently providing coverage for the entire country. Ambulance Service in Wales operates on a similar system, while the Scottish Ambulance Service and Northern Ireland Ambulance Service are single entities provided by the Health Departments of their respective devolved governments. Additional coverage, particularly for special events, may be provided by Voluntary Ambulance Services, including the British Red Cross and St. John Ambulance, or by private companies, but neither of these typically uses fully qualified paramedics.
In Canada, paramedics are employed almost exclusively by publicly operated EMS systems. The manner in which such systems are organized and funded varies somewhat from province to province. The British Columbia Ambulance Service is organized as a branch of the provincial government, with that government providing services directly through a branch of the Ministry of Health. In Ontario, the provision of EMS has been allocated to Upper-tier municipalities (like U.S. Counties). Each of these provides its own EMS, and is free to operate the service directly as third service or, in rare cases, as a branch of the fire department, or to contract those services to a private business entity or a local hospital. In all of these cases, the provincial government accredits the services, and provides operating standards and some funding. In the Maritime Provinces the provincial governments have entered into long term contractual arrangements with a single private company for the operation of their EMS systems. Other Canadian provinces use still other approaches to the provision of service and the operating environment in which paramedics will work.
In Australia, paramedics work exclusively for the State Ambulance Service, including Ambulance Victoria service (http://www.ambulance.vic.gov.au/), among others. Public ambulance services in Australia are exclusively third-service option. These services are operated directly by each of the states and territories. A separate service is provided for the Australian Capital Territory. Unlike the U.S., Australian paramedics are not typically employed in hospitals or the fire brigade. While there are a handful of private ambulance companies operating in Australia, these do not typically provide what would normally be described as 'paramedic' levels of service.
In some centers, some paramedics have begun to specialize their practice. This specialization frequently is to some degree tied to the environment in which the paramedic will work. One of the earliest examples of this involved aviation medicine, and the use of helicopters. Another was the transfer of critical care patients between facilities. While some jurisdictions still use physicians, nurses and technicians for this purpose, increasingly, this role falls to specially-trained, very senior and experienced paramedics, who perform this role as their primary job function. Other areas of specialization include such roles as tactical paramedics working in police tactical units, marine paramedics, hazardous materials (Hazmat) teams, and Heavy Urban Search and Rescue. Still others work in physical isolation, on offshore oil platforms, oil and mineral exploration teams, and in the military. In some cases, one can even find paramedics working on cruise ships. A new and evolving role for paramedics involves the expansion of their practice into the provision of relatively simple primary health care and assessment services.
Examples of skills performed by paramedics
Skills by certification level
Although there is a great deal of variation in what paramedics are trained and permitted to do from region to region, some skills performed by paramedics include:
Skills common to all EMTs and paramedics
Spinal injury management, including immobilization and safe transport.
Fracture management, including assessment, splinting, and use of traction splints where appropriate.
Obstetrics, assessment, assisting with uncomplicated childbirth, recognition of and procedures for obstetrical emergencies, such as breech presentation, cord presentation, placental abruption.
Management of burns, including classification, estimate of surface area, recognition of more serious burns, and 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.
Triage of patients in a mass casualty incident.
Emergency vehicle operation.
Medications administered
Paramedics in most jurisdictions administer a variety of emergency
medications. The specific medications vary widely, based on physician medical director preference, local standard of care, and law, but may include:
Adenosine, which is used to slow down heartbeats that are too fast (doing so by stopping the heart for a short period of time--half life of Adenosine (ATP) is 12 seconds)
Atropine, which will speed up a heartbeat that is too slow.
Sympathomimetics like dopamine for severe hypotension (low blood pressure) and cardiogenic shock.
D50W (Dextrose 50%) to treat hypoglycemia (low blood sugar)
Sedatives like Versed, Ativan, or Etomidate, and paralytics such as succinylcholine, rocuronium, or vecuronium to perform rapid sequence induction (RSI), a procedure to quickly induce anesthesia prior to tracheal intubation
Antipsychotics like Haldol or Geodon to sedate combative patients
Albuterol, atrovent, and methylprednisolone to treat respiratory conditions.
Medications to relieve pain or decrease nausea and vomiting.
Nitroglycerin, aspirin, and morphine sulfate for cardiac ailments.
Antiarrhythmics like amiodarone to treat cardiac arrhythmias such as ventricular tachycardia and ventricular fibrillation.
Narcotics like morphine sulfate, pethidine, fentanyl and in some jurisdictions, ketorolac to treat severe pain, i.e. burns or fractures.
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. The material included here is, however, fairly typical and representative.
Paramedics by country
Paramedics in Australia
Paramedics in Canada
Paramedics in France
Paramedics in Germany
Paramedics in Ireland
Paramedics in South Africa
Paramedics in the United Kingdom
Paramedics in the United States
Medicolegal authority
Paramedics normally function under the authority (medical direction) of one or more physicians charged with legally establishing the emergency medical directives for a particular region. Paramedics are credentialed and authorized by these physicians to use their own clinical judgment and diagnostic tools to identify medical emergencies and to administer the appropriate treatment, including drugs that would normally require a physician order. Credentialing may occur as the result of a State Medical Board examination (U.S.) or the
National Registry of Emergency Medical Technicians (U.S.). In the UK, and in some parts of Canada, credentialing may occur by means of a College of Paramedicine (http://www.britishparamedic.org/). In these cases, paramedics are regarded as a self-regulating health profession. The final common method of credentialing is through certification by a Medical Director and permission to practice as an extension of the Medical Director's license to practice medicine. The authority to practice in this semi-autonomous manner is granted in the form of standing order
protocols (off-line medical control) and in some cases direct physician consultation via phone or radio (on-line medical control). Under this paradigm, paramedics effectively assume the role of out-of-hospital field agents to regional emergency physicians, with independent clinical decision-making authority that is typically enjoyed only by expert clinicians within the hospital setting. In some parts of Europe, those in the paramedic role are only permitted to practice many of their advanced skills while assisting a physician who is physically present, except in cases of immediately life-threatening emergencies. In certain other jurisdictions, such as the United Kingdom and South Africa, paramedics may be entirely autonomous practitioners capable of prescribing medications.
In the media
The 1970s television show
Emergency! was a very popular series which centered on the work of paramedics in the
Los Angeles County Fire Department, and the staff at the fictional Rampart Emergency Hospital.
Emergency! has been widely credited with inspiring many municipalities in the United States to develop their own paramedic programs, and has inspired many to enter the fields of emergency medicine. The show was a top-rated program for its entire production run (1972–1979), as well as in
syndicated television reruns – even inspiring a Saturday morning
cartoon series.
Mother, Jugs & Speed is a 1976 comedy film, starring Bill Cosby, Raquel Welch, and Harvey Keitel. The film depicts a private ambulance company struggling to survive in Los Angeles, and, while not necessarily showing the profession in its most flattering light and taking some real liberties for comedic value, provides a fairly honest illustration of the state of the ambulance industry just prior to its professionalization as EMS.
Casualty is a long-running BBC television series, depicting the staff of the Accident and Emergency Department of the fictional Holby City Hospital, and the English paramedics who work with them. It provides an interesting, human, and realistic view of English paramedics. The show has been filmed on location in Bristol, England, and has run continuously since the mid 1980s, spinning off another series, Holby City, and a number of made-for-television films. It has been described as 'one of Britain's most beloved medical dramas'.
Paramedics is also the name of a show on the Discovery Health Channel, which details the life and work of emergency medical squads in major urban centers in the United States. It is also the name of a 1988 comedy which highlighted the lighter side of EMS.
Paramedic: On the Front Lines of Medicine (1998), by Peter Canning, is an autobiographical account of a paramedic's first year on the job. Rescue 471: A Paramedic's Stories (2000) is the sequel.
Bringing Out the Dead (1999), directed by Martin Scorsese and starring Nicolas Cage, is one of very few films about paramedics. The main character is paramedic Frank Pierce, who works in New York's Hell's Kitchen. He's become burned out and haunted by visions of the people he's failed to save including a little girl. The film is based on the novel of the same name by Joe Connelly, a former New York City paramedic.
Into the Breach: A Year of Life and Death with EMS (2002), book written by J.A. Karam, is the true story of paramedics, emergency medical technicians, and heavy-rescue specialists fighting to control trauma and medical emergencies.
Parts of Third Watch (1999) were devoted to adventures of the fictional 55th precinct FDNY EMS unit, created by ER executive producer John Wells.
Saved (2006) is a TNT series centered on fictional paramedic Wyatt Cole (Tom Everett Scott), his partner, and their chaotic lives on and off the job.
Black Flies (2008) is a novel written by Shannon Burke, based on his experiences working as a paramedic in Harlem, New York City.
Trauma (2009) portraits a group of San Francisco Fire Department paramedics and EMT's and a fictional medical helicopter transport service "Angel Rescue Services", working in concert with of the fictional trauma center San Francisco City Hospital. The high-action medical drama stars Derek Luke, Cliff Curtis, Anastasia Griffith, Kevin Rankin, Aimee Garcia, Billy Lush, Jamey Sheridan, and Taylor Kinney.
See also
National Association of Emergency Medical Technicians
National Registry of Emergency Medical Technicians
Flight Paramedic
Critical Care Emergency Medical Transport Program
Emergency!
Biophone
References
American Heart Association (January 2006)
US DOT
External links
National Registry of Emergency Medical Technicians
National Association of Emergency Medical Technicians
NHTSA Emergency Medical Services National Page
Paramedic Training Courses
Category:Emergency medical responders
Category:Healthcare occupations
Category:Protective service occupations
