Paramedics in the United States

Star of Life

In the United States, the paramedic is a paraprofessional whose primary focus is to provide advanced emergency medical care for critical and emergency patients who access Emergency Medical Services (EMS). This individual possesses the complex knowledge and skills necessary to provide patient care and transportation. Paramedics function as part of a comprehensive EMS response, under medical oversight. Paramedics perform interventions with the basic and advanced equipment typically found on an ambulance. The paramedic is a link from the scene into the health care system. One of the eligibility requirements for state certification or licensure requires successful completion of a nationally accredited Paramedic program at the certificate or associate degree level.^[1] Each state varies in requirements to practice as a paramedic and not all states require licensure.

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 or the required equipment carried inside. Around 1966 in a published report entitled "Accidental Death and Disability: The Neglected Disease of Modern Society",^[2] (known in EMS trade as the White Paper) medical researchers began to reveal, to their astonishment, that soldiers who were seriously wounded on the battlefields of Vietnam had a better survival rate than those individuals who were seriously injured in motor vehicle accidents on California freeways. Early research attributed these differences in outcome to a number of factors, including comprehensive trauma care, rapid transport to designated trauma facilities, and a new type of medical corpsman; one who was trained to perform certain critical advanced medical procedures such as fluid replacement and airway management, which allowed the victim to survive the journey to definitive care.

During the 1960s a Los Angeles cardiologist named Walter S. Graf became concerned about the lack of actual medical care being given to coronary patients during emergency transportation to a hospital. In 1969, while serving as president of the Los Angeles Chapter of the American Heart Association, he created a "mobile critical care unit", consisting of a Chevy van, a registered nurse, and a portable defibrillator.^[3] The same year his patient Kenneth Hahn, a member of the Los Angeles County Board of Supervisors, persuaded the Supervisors to approve a pilot program to train county firefighters as "Mobile Intensive Care Paramedics". A change in state law was necessary to allow personnel other than doctors and nurses to render emergency medical care. Hahn recruited two state legislators who wrote the Wedworth-Townsend Paramedic Act of 1970, signed into law by Governor Ronald Reagan on July 15, 1970, despite opposition from doctors, nurses, and attorneys. Paramedic training began the next month at the Freeman Memorial Hospital under Graf's direction.^[4] It was the first nationally accredited paramedic training program in the United States.^[5]

Other communities in the United States were also experimenting with advanced emergency medical care. Pittsburgh's branch of Freedom House paramedics are credited as the first emergency medical technician (EMT) trainees in the United States. Pittsburgh's Peter Safar is referred to as the father of CPR.^[6] In 1967, he began training unemployed African-American men in what later became Freedom House Ambulance Service,^[7][8] the first paramedic squadron in the United States.^[9][10] Almost simultaneously, and completely independent from one another, experimental programs began in three U.S. centers; Miami, Florida; Seattle, Washington; and Los Angeles, California. Each was aimed at determining the effectiveness of using firefighters to perform many of these same advanced medical skills in the pre-hospital setting in the civilian world. Many in the senior administration of the fire departments were initially quite opposed to this concept of 'firemen giving needles', and actively resisted and attempted to cancel pilot programs more than once. In Seattle, the Medic One program at Harborview Medical Center and the University of Washington Medical Center, started by Leonard Cobb, M.D., began training firefighters in CPR in 1970.^[11] Dr. Eugene Nagel trained city of Miami firefighters as the first U.S. paramedics to use invasive techniques and portable defibrillators with telemetry in 1967.^[12]

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,^[13] the father of trauma medicine, devised the concept of integrated emergency care, designing the first civilian Medevac helicopter program and campaigning for a statewide EMS system. Other communities that were early participants in the development of paramedicine included Jacksonville, Florida, Pittsburgh, Pennsylvania (in an expanded program), and Seattle, Washington (in an expanded program). In 1972 the first civilian emergency medical helicopter transport service, Flight for Life opened in Denver, Colorado.^[14] Emergency medical helicopters were soon put into service elsewhere in the United States. It is now routine to have paramedic and nurse-staffed EMS helicopters in most major metropolitan areas. The vast majority of these aeromedical services are utilized for critical care air transport (inter-hospital) in addition to emergency medical services (pre-hospital).

A television producer, working for producer Jack Webb,^[15] of Dragnet and Adam-12 fame, was in Los Angeles' UCLA Harbor Medical Center, doing background research for a proposed new TV show about doctors, when he happened to encounter these 'firemen who spoke like doctors and worked with them'. This novel idea would eventually evolve into the Emergency! television series, which ran from 1972–1977, portraying the exploits of a new group called 'paramedics'. The show captured the imagination of emergency services personnel, the medical community, and the general public. When the show first aired in 1972, there were only 6 full-fledged paramedic units operating in 3 pilot programs (Miami, Los Angeles, Seattle) in the whole of the United States. No one had ever heard the term 'paramedic'; indeed, it is reported that one of the show's actors was initially concerned that the 'para' part of the term might involve jumping out of airplanes! By the time the program ended production in 1977, there were paramedics operating in every state. The show's technical advisor was a pioneer of paramedicine, James O. Page,^[16] then a Battalion Chief responsible for the Los Angeles County Fire Department 'paramedic' program, but who would go on to help establish other paramedic programs in the U.S., and to become the founding publisher of the Journal of Emergency Medical Services.^[17]

Throughout the 1970s and 1980s, the field continued to evolve, although in large measure, on a local level. In the broader scheme of things the term 'ambulance service' was replaced by 'emergency medical service' to reflect the change from a transportation system to a system that provides actual medical care. The training, knowledge base, and skill sets of both paramedics and emergency medical technicians (both competed for the job title, and 'EMT-Paramedic' was a common compromise) were typically determined by what local medical directors were comfortable with, what it was felt that the community needed, and what could actually be afforded. There were also tremendous local differences in the amount and type of training required, and how it would be provided. This ranged from in-service training in local systems, through community colleges, and ultimately even to universities. During the evolution of paramedicine, a great deal of both curriculum and skill set was in a state of constant flux. Permissible skills evolved in many cases at the local level, and were based upon the preferences of physician advisers and medical directors. Treatments would go in and out of fashion, and sometimes, back in again. The use of certain drugs, Bretylium for example, illustrate this. In some respects, the development seemed almost faddish. Technologies also evolved and changed, and as medical equipment manufacturers quickly learned, the pre-hospital environment was not the same as the hospital environment; equipment standards that worked fine in hospitals could not cope well with the less controlled pre-hospital environment.

Physicians began to take more interest in paramedics from a research perspective as well. By about 1990, most of the 'trendiness' in pre-hospital emergency care had begun to disappear, and was replaced by outcome-based research and evidence-based medicine;^[18] 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.^[19] Such changes affected everything from simple procedures, such as CPR, to changes in drug protocols and other advanced procedures.^[20] 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.

• American paramedics at work
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  In the E/R

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  Managing a trauma patient

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  Bicycle paramedics, Los Angeles, California

Education

The education and skills required of paramedics vary by state. The U.S. National Highway Traffic Safety Administration (NHTSA) designs and specifies a National Standard Curriculum^[21] 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.^[22] The National Registry of Emergency Medical Technicians (NREMT) is a private, central certifying entity whose primary purpose is to maintain a national standard. NREMT also provides certification information for paramedics who relocate to another state.^[23]

Paramedic education programs can be as short as 6 months or as long as 4 years. An associate degree program is 2 years, often administered through a community college. Degree programs are an option, with two year associate degree programs being most common, although four year bachelor's degree programs exist. Many paramedic programs are through Adult Career and Technical schools that provide a certificate of completion upon completion of the program. All programs must meet the current National Standard curriculum. The institutions offering such training vary greatly across the country in terms of programs and requirements, and each must be examined by the prospective student in terms of both content and requirements where the prospective paramedic hopes to practice.^[24] Regardless of education, all students must meet the same state requirements to take the certification exams, including the National Registry exams which consist of a psychomotor skills practical examination and the a Computer Based Testing (CBT). In addition, most locales require that paramedics attend ongoing refresher courses and continuing medical education to maintain their license or certification. In addition to state and national registry certifications, most paramedics are required to be certified in Pediatric Advanced Life Support, Pediatric Prehospital care or Pediatric Emergencies for the Prehospital Provider; Prehospital Trauma Life Support; International Trauma Life Support; and Advanced Cardiac Life Support. These additional requirements have education and certification from organizations such as the American Heart Association.

Credentialling and oversight

In the U.S., the community college training model remains the most common, although some university-based paramedic education models exist. These variations in both educational approaches and standards has led to tremendous differences from one location to another. There may be situations in which a group of people with 120 hours of training, and another group (in another jurisdiction) with university degrees, were both calling themselves 'paramedics'. There were some efforts made to resolve these discrepancies. The National Association of Emergency Medical Technicians (NAEMT) along with National Registry of Emergency Medical Technicians (NREMT)^[25] attempted to create a national standard by means of a common licensing examination, but to this day, this has never been universally accepted by U.S. States, and issues of licensing reciprocity for paramedics continue, although if an EMT obtains certification through NREMT (NREMT-P, NREMT-I, NREMT-B), this is accepted by 40 of the 50 states in the United States.^[26] This confusion was further complicated by the introduction of complex systems of gradation of certification, reflecting levels of training and skill, but these too were, for the most part, purely local. To clarify, at least at a national level, the National Highway Traffic Safety Administration (NHTSA), which is the federal organization with authority to administer the EMS system, defines the various titles given to prehospital medical workers based on the level of care they provide. They are EMT-P (Paramedic), EMT-I (Intermediate), EMT-B (Basic), and First Responders. While providers at all levels are considered emergency medical technicians, the term "paramedic" is most properly used in the United States to refer only to those providers who are EMT-P's. Apart from this distinction, the only truly common trend that would evolve was the relatively universal acceptance of the term 'emergency medical technician' being used to denote a lower level of training and skill than a 'paramedic'.

Changes in procedures also included the manner in which the work of paramedics was overseen and managed. In the earliest days of the field, medical control and oversight was direct and immediate, with paramedics calling into a local hospital and receiving orders for every individual procedure or drug.^[27] 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.^[28] 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

These are the minimum skills recommendations put forth by the National Highway Traffic Safety Administration and endorsed by the National Registry of Emergency Medical Technicians.^[29] Each State, region, and agencies may add to or deduct from this list as they see medically fit.

Skills common to all EMTs and paramedics

• 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 many jurisdictions administer a variety of emergency medications; the individual medications vary widely, based on physician (medical director) direction and local law. These drugs may include Adenocard (Adenosine),^[30] which stops and resets a heart that is beating too rapidly, and Atropine, which speeds a heartbeat that is too slow. The list may include sympathomimetics like dopamine for severe hypotension (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, Ativan, or Etomidate, and paralytics such as succinylcholine, rocuronium, or vecuronium.^[31] Paramedics in some jurisdictions may also be permitted to sedate combative patients using antipsychotics like Haldol or Geodon.^[32] The use of medications for treating respiratory conditions such as, albuterol, atrovent, and methylprednisolone 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 to treat cardiac arrhythmias such as ventricular tachycardia and ventricular fibrillation not responding to defibrillation.^[33] Paramedics also treat for severe pain, i.e. burns or fractures, with narcotics like morphine sulfate, pethidine, fentanyl and in some jurisdictions, ketorolac. 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 service providers. These include private ambulance services, fire departments, public safety or police departments, hospitals, law enforcement agencies, the military, and municipal EMS agencies in addition to and independent from police or fire departments, also known as a 'third service'. Paramedics may respond to medical incidents in an ambulance, rescue vehicle, helicopter, fixed-wing aircraft, motorcycle, or fire suppression apparatus.

Example of an official shoulder emblem worn by paramedics to identify their advanced level of care.

Paramedics may also be employed in medical fields that do not involve transportation of patients. Such positions include offshore drilling platforms, phlebotomy, blood banks, research labs, educational fields, law enforcement and hospitals.^[34]

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 Emergency Nursing may work 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 pumps, and mechanical ventilators.^[35]
• Tactical paramedics work on law enforcement teams (SWAT). 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.^[36] The advantage to having dual role paramedics is that medical care is provided almost immediately.
• Hospital paramedics are sometimes employed in either of the outpatient and inpatient areas. Emergency departments employ the largest number of paramedics working inside of hospitals. Considered ambulatory care, emergency departments are classified as an outpatient area of a hospital. Depending on their scope of practice and job description within the emergency department, paramedics are allowed to triage and assess incoming patients, provide analysis and interpretation of both labs and EKGs, intravenous therapy, drug administration, transportation of emergency department patients to diagnostic testing or their inpatient rooms. Paramedics are also employed indireclty in the inpatient areas of hospitals as well. Paramedics are utilized in intensive care units assisting other licensed staff with ICU patients and they are utilized on high risk transport teams by providing transportation, continuation of care and assisting in sedation of patients during minimally invasive and invasive procedures at the bedside and in diagnostic areas. Because of the nature and purpose of these teams, paramedics work closely with radiology, interventional radiology, nuclear medicine and anesthesiology.

Salary

The salary of a paramedic in the US varies. The mean average is $30,000, with the lowest 10% earning under $20,000 and the top 10% make over $50,000, considerably less than the salaries of paramedics in Canada. Paramedic supervisors and managers may make between $60,000- $80,000, depending the location.

See also

• Flight Paramedic
• Emergency medical responder levels by state

References

2. National Academy of Sciences and National Research Council. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: The National Academies Press, 1966.

External links

• National Association of Emergency Medical Technicians Homepage
• National Registry of Emergency Medical Technicians
• NHTSA Emergency Medical Services National Page
• Paramedicine.com