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Paramedic

From Academic Kids

Typical view of the defibrillator operator. The leader is at the head of the patient, administrating oxygen. Note how the head of the patient in secured between the leader's knees. The defibrilation patches are on.
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Typical view of the defibrillator operator. The leader is at the head of the patient, administrating oxygen. Note how the head of the patient in secured between the leader's knees. The defibrilation patches are on.

A paramedic is a trained and licensed or certified medical professional. Most commonly, paramedics are those who respond to medical emergencies out in the field (pre-hospital) for the purpose of stabilizing the victim's condition so s/he can be transported to medical facilities.

The paramedic is a type of emergency medical technician (EMT). In the United States, emergency medical technicians are classified according to their level of training. The National Registry of EMTs is a private, central certifying entity, with individual states usually set their own standards of licensure. All EMTs must meet the minimum requirements as set forth in the Department of Transportation's standards for EMT curriculum. The National Registry of Emergency Medical Technicians recognizes three levels of EMT: EMT-B (Basic), EMT-I (Intermediate) and EMT-P (Paramedic). The paramedic level is the highest level of nationally registered positions. In addition to the basic-level skills of CPR, first aid, airway management, oxygen administration, spinal immobilization, traction splinting, bleeding control and splinting, as well as the intermediate skills of IV therapy, endotracheal intubation and initial cardiac drug therapy, the paramedic is also educated in EKG interpretation, advanced airway skills to include RSI, pharmacology, trauma resuscitation, pediatric life support and advanced cardiac life support. Most states require ongoing continuing education and verification of clinical skills capability to maintain a paramedic certification.

Paramedics are employed by various public and private emergency services providers. These include private ambulance services, fire departments (as firefighters), hospitals, law enforcement agencies, the military, or various EMS-specific, or "third service" public safety agencies. Paramedics may respond to medical incidents in an ambulance, rescue vehicle, helicopter, fixed-wing aircraft, and increasingly in fire suppression apparatus.

As nursing shortages become more and more prevalent, paramedics are increasingly used in Emergency Departments and Intensive Care Units of hospitals. Often, paramedics operate with greater lattitude and autonomy than many nurses. In addition, paramedics are often used as chief medical personnel on offshore drilling platforms and on MEDEVACs and airplanes. However, paramedics may be employed in many different medical fields that do not necessarily involve transportation of patients. Such positions may include phlebotomy, blood banks, research labs and educational fields.

In the U.S., paramedic salaries can range anywhere from unpaid, volunteer positions to around $60,000 a year, depending on location and experience. It should be noted that volunteer paramedics can generally provide the same level of care as those performing the service in a career capacity, depending on the local scope of practice.

Contents

History

Prior to the 1970s, ambulances were staffed with advanced first-aiders and were frequently referred to as "ambulance drivers." There was little regulation or standardized training for those staffing these early emergency response vehicles. However, after the release of the National Highway Traffic Safety Administration's "White Paper" on motor vehicle fatalities, a concentrated effort was undertaken to improve emergency medical care in the prehospital setting.

Pittsburgh, Pennsylvania, Portland, Oregon and Seattle, Washington were early pioneers in prehospital emergency medical training. Pittsburgh's Freedom House paramedics are credited as the first EMT trainees in America. Portland's Leonard Rose, M.D., in cooperation with Buck Ambulance Service, instituted a cardiac training program and began to train other paramedics. 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. At the same time, the Los Angeles County Fire Department also began training some of their firefighters in emergency care. This was vividly portrayed in the television show, Emergency! which helped popularize the emergency medical service around the world.

The first paramedics began operating in the 1970's with expansion throughout the country since that time.

A few years later, emergency medical helicopters or MEDEVACs were put into service in the Denver and A.L.E.R.T. (http://www.krmc.org/)Kalispell, Montana areas. 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).

Critical care transports are usually requested when a medical treatment facility (usually a smaller hospital) does not have the personell, equipment, and/or services to properly treat a patient. The patient is then rapidly transported to another medical treatment facility (usually a large hospital or health system located in close proximity to or within highly populated areas) that has the capability to either definitively treat or to extend or enhance treatment to a higher level. These critical care transports can occur by ground ambulance or aircraft. They are usually the reason why a nurse is needed in addition to a paramedic in the transport team. The nurse usually has experience and may be credentialled in critical care medicine. Recently, paramedics have received critical care medical training both in the initial paramedic certification course as well as continuing education courses such as the Critical Care Emergency Medical Transport Program (CCEMTP).

The employment of paramedics depends on the organizations that operate the ambulances and other emergency vehicles which they are deployed in. Paramedics responding to a typical emergency may work for the local fire department and arrive in a fire truck or an ambulance bearing the department's insignia, work for a private corporation such as a private ambulance and medical transport company, or work for a hospital or health care system.

Training

Paramedics receive at least two years of intensive training. Many universities now offer four-year degrees in emergency medical services, but as a relatively young industry, professional standards and training levels are still evolving.

Paramedics are trained to deal with a broad range of emergency medical situations. These include: obstetrics, cardiac, airway and breathing, a vast array of medical emergencies, orthopedics, psychological and mental health emergencies, pediatrics, trauma, vehicle extrication, communications, intravenous therapy, pharmacology, and advanced cardiac life support. In addition, most locales require paramedics to attend an ongoing schedule of refresher courses in order to maintain their license and/or certification.

Specifically, paramedics are trained in intubation, including pharmacologically assisted intubation and increasingly in rapid sequence induction, advanced cardiac life support, including cardiac monitoring, 12-lead electrocardiograms, synchronized cardioversion and transcutaneous pacing; pediatric advanced life support, intravenous cannulation, needle chest decompression, needle cricothyroidotomy, and the administration of a wide range of medications such as nitroglycerin, benzodiazepines such as lorazepam, opioids and dextrose.

The National Registry requires continuing education and clinical skill verification for biannual recertification of both EMT-Basic and paramedic-level personnel.

The Future

Gone are the days, at least in the urban setting, of untrained ambulance drivers. Those in need of emergency medical care have come to expect highly trained medical professionals within four to six minutes of the onset of their emergency. Rapid treatment and transport to a qualified medical facility follow the care given by paramedics in the field.

Paramedics may arrive by fire truck or ambulance and may be involved in initial care and/or transportation, depending on local response strategies and funding levels. In some areas, fire departments and law enforcement agencies provide a "first response" capability, that includes use of automatic external defibrillators, or AED's.

In the future, we will see fire agencies provide increasing levels of emergency medical services. Granted, even now, due to the success of fire prevention activities, 80% of the services provided by most fire departments involved emergency medical response. Nontraditional agencies such as the Highway Patrol may also increase their involvement in providing paramedic-level emergency medical services.

Paramedics in France

Until very recently, the French pre-hospital care strategy was based on either first responders (firemen) or prehospital medical teams (MD + nurse + ambulance driver) called Smur (service mobile d'urgence et de réanimation, emergency resuscitation mobile unit). With this organisation, any situation requiring a paramedic is handled by a physician who specialises in pre-hospital emergencies.

Due to a lack of physicians, interhospital transportation requiring intensive care was often performed by an ambulance driver and a nurse working on protocol, although it was not entirely legal (the nurses are allowed to apply a medical protocol, but the definition of a Smur necessarily includes a MD). In any case, the protocols had to be written specifically for a patient, so such protocols could not be used for pre-hospital emergencies (the patient was not seen by the MD who wrote the protocol). The situation is evolving, and nurses belonging to a fire department (or ISP–infirmier sapeur-pompier) can now apply emergency protocols in pre-hospital situations, in the same way as paramedics. They can also receive oral prescriptions by phone or radio and thus provide specialised care.

Therefore, there is no specific paramedic profession in France, but the existing nursing profession have evolved to meet the needs of pre-hospital care.

Paramedics in Canada

In Canada the scope of practice of Paramedics is described by the National_Occupation _Competency_Profile_for_Paramedics (http://www.paramedic.ca/nocp.html) document developed by the Paramedic_Association_of_Canada (http://www.paramedic.ca) for the Federal Goverment. Unlike the United States, in Canada all providers that work in Ambulances are identified as 'Paramedics'. There is currently some minor variation in this - for example, the province of Alberta still uses the title 'EMT' - but almost all provinces are moving to using the new titles.

The three levels of qualification that exist are Primary Care Paramedic, Advanced Care Paramedic and Critical Care Paramedic. Primary Care Paramedics perform Automated External Defibrillation, administer what are called 'Symptom Relief Medications' (Oxygen, SQ Epinephrine, Glucagon, Ventolin, etc.) and perform spinal immobilization and other basic medical care. Advanced Care Paramedics carry approximately 20 different medications, perform surgical airways, intubate, perform needle decompression of tension pneumothorax, use basic transport ventilators and perform and interpret 12 lead ECGs. Synchronized cardioversion and transcutaneous pacing are also included in their scope of practice. Several sites in Canada have experimented with pre-hospital fibrinolytics, and this is expected to gradually become a part of the ACP standard of care. Critical Care Paramedics carry 60+ medications, perform rapid sequence intubation, run medication pumps, use ICU quality transport ventilators, run intra-aortic balloon pumps on their own, use transvenous pacers, and monitor central lines - among other things. Essentially, they run a mobile intensive care unit. CCPs work in close cooperation with their controlling physicians, and do not require additional medical staff to accompany any of their patients.

Paramedic training in Canada is intense, as paramedics are seen as medical professionals fully akin to nurses, respiratory therapists, cardiac perfusionists and others. Primary Care Paramedicine is a two year program, though some Colleges teach it in an intensive, one-year program. Training as an Advanced Care Paramedic usually requires a mandatory period of experience working as a Primary Care Paramedic - usually one to three years. The ACP training program usually takes 1-3 semesters of study. Training as a Critical Care Paramedic also requires mandatory field experience as an Advanced Care Paramedic and also takes 1-3 semesters of study, depending on the institution. Paramedic training at all levels involves supervised, intensive classroom, lab, clinical and field experience. There is a strong movement toward degree paramedicine in Canada and several Universities are offering degree programs in conjunction with Community Colleges. The education of paramedics in Canada is accredited by the Canadian_Medical_Association's_Committee_on_Conjoint_Accreditation (http://www.cma.ca/index.cfm/ci_id/19316/la_id/1.htm) and a list of accredited programs can be found on their site.

Because paramedics are seen as 'physician extenders' they enjoy a close relationship with physicians who ultimately grant paramedics the legal right to practice their profession. Also, because physician assistants exist primarily only in the military in Canada, the role of 'Clinical Paramedic' is gradually expanding. Centre's such as Halifax, Nova Scotia have paramedics working in -hospital on cardiac arrest teams and on in-hospital patient transfer teams.

Paramedics are well paid and enjoy good benefits in most provinces. Paramedics in Canada generally work only as paramedics - not as cross trained fire fighters or police officers - and most are full time professionals. In the first quarter of 2005 paramedics were granted status federally as a "Public Safety Occupation" which means that paramedics are now eligible for early retirement, as are police officers and fire fighters. Many EMS agencies such as Toronto_EMS (http://www.city.toronto.on.ca/ems/) run a full range of paramedic specialty squads including Marine medics, Bike medics, First Response medics, Tactical medics, CBRN medics (Chemical, Biological, Radiological and Nuclear) and HUSAR medics (Heavy Urban Search And Rescue - specializing in urban disaster recovery).

Toronto_EMS (http://www.city.toronto.on.ca/ems/) is also the largest municipal ambulance service in Canada with 920 active paramedics in 146 ambulance transport units and a 2002 call volume of:

  • 425,000 Phone Calls via the 9-1-1 system
  • 247,000 Requests for service
  • 187,000 Responses
  • 140,000 Emergency patient transports

The Association representing close to 300 of Toronto's Paramedics is known as the Toronto Paramedic Association, and can be reached at their website (http://www.torontoparamedicassociation.com).


The British Columbia Ambulance Service (http://www.healthservices.gov.bc.ca/bcas), is the sole provider of pre-hospital emergency care at the paramedic level of care. Some stats:

Coverage

  • 3.9 Million Population
  • 926,492 sq. km. coverage area

Paramedics And Equipment

  • 3,177 Total field paramedics/EMA's
  • 450 Total ambulances and support units
  • 190 Total ambulance stationsfr:Secours paramédicaux

de:Rettungsassistent

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