Paramedics in the United States

In the United States, a paramedic is the most advanced prehospital medical professional who responds to and treats medical emergencies and trauma outside of an emergency room. Paramedics typically provide treatment on scene and during transportation to a hospital emergency department. Occasionally, paramedics treat conditions that do not require hospitalization, such as during public gatherings or other large events ("event standby"). They derive the legal authority to practice pre-hospital medical care in the field through the license of a physician, who serves as the "medical director". Paramedics serve as an out-of-hospital extension of emergency services typically offered by medical doctors within the hospital emergency department. In some states, Paramedics are also called 'Mobile Intensive Care Paramedics' or MICPs and staff ambulances or other vehicles known as Mobile Intensive Care Units, or MICUs, further emphasizing the advanced treatment modalities employed by the paramedic.

The National Highway Traffic Safety Administration (NHTSA), the federal organization with authority to administer the EMS system in the United States, defines the various titles given of 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. (Individual states may have different classifications.) While providers at all levels are considered Emergency Medical Technicians, the term "Paramedic" is most properly used to refer only to those providers who are EMT-P's.

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. 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.

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 medicine 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 pumps, and mechanical ventilators.

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.

In-Hospital paramedics are increasingly employed in hospital emergency departments and intensive care units due to the nursing shortage. In emergent situations, paramedics are generally accustomed to practicing with greater latitude and autonomy than Registered Nurses due to their specialized training, which emphasizes discretionary decisions and treatment without mandatory physician consultation. [cite web
title=Comparison of Paramedics and Emergency Nurses
url=http://www.jems.com/news_and_articles/articles/The_View_from_the_Other_Side.html
accessdate=2008-02-03 ]

Skills performed by paramedics

Protocols vary by state and EMS system. Listed are some of the skills commonly performed by paramedics across the United States.

*Bandaging
*Splinting
*Advanced Cardiac Life Support (ACLS)
*Cardioversion and Defibrillation
*Advanced airway management, including suctioning, and Endotracheal Intubation
*Rapid Sequence Intubation
*Medical and Trauma Assessments and Triage
*Spinal Immobilization
*Administration of numerous medications (see below)
*Traction Splinting
*Intravenous therapy
*Intraosseous infusion
* Needle Thoracotomy
* Surgical Cricothyrotomy
*Nasogastric tube insertion
*Transcutaneous Pacing
*Advanced EKG Monitoring and 12-Lead EKG Interpretation
*Continuous Positive Airway Pressure (CPAP)
*Portable Ventilator managament
*Obstetrics including delivery, neonatal resuscitation, and post-delivery maternal care

Paramedics frequently receive additonal specialized training, including Advanced Cardiac Life Support, Advanced Medical Life Support (AMLS), Prehospital Trauma Life Support (PHTLS), Emergency Pediatric Care (EPC), Pediatric Advanced Life Support (PALS), and the Neonatal Resuscitation Program (NRP).

Pharmacology / Medication Administration

Paramedics in the United States receive extensive training in pharmacology in order to administer a variety of Medications in the field, approved by local Medical Directors.

*Oxygen
*Aspirin
*Nitroglycerin
*Epinephrine
*Norepinephrine
*Atropine Sulfate
*Amiodarone
*Lidocaine
*Adenosine
*Valium
*Ativan
*Versed
*Calcium Chloride
*Magnesium Sulfate
*Sodium Bicarbonate
*Benadryl
*Dextrose (D50, D25, Oral Glucose, other dextrose-containing solutions)
*Lasix
*Dopamine
*Glucagon
*Ipratropium Bromide
*Albuterol
*Oxytocin
*Phenylephrine Nasal Spray
*Morphine
*Fentanyl
*Demerol
*Toradol
*Thiamine
*Succinylcholine
*Vecuronium
*Etomidate
*Narcan
*Flumazenil
*Mannitol
*Cardizem
*Labetalol
*Reglan
*Phenergan
*Vasopressin
*Dilantin
*Haldol
*Zofran
*Solu-Medrol
*Dexamethasone
*Alupent
*Procainamide

Education

The education and skills required of paramedics vary by state. The NHTSA designs and specifies a National Standard Curriculum [cite web
title=National Standard Curriculum
url=http://www.nhtsa.dot.gov/portal/site/nhtsa/template.MAXIMIZE/menuitem.2a0771e91315babbbf30811060008a0c/?javax.portlet.tpst=4670b93a0b088a006bc1d6b760008a0c_ws_MX&javax.portlet.prp_4670b93a0b088a006bc1d6b760008a0c_viewID=detail_view&javax.portlet.begCacheTok=com.vignette.cachetoken&javax.portlet.endCacheTok=com.vignette.cachetoken&itemID=1822abcc80c81010VgnVCM1000002c567798RCRD&overrideViewName=Article
accessdate=2007-08-08 ] 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. [http://www.nremt.org 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 [cite web
title=State Office Information
url=http://www.nremt.org/EMTServices/emt_cand_state_offices.asp
accessdate=2007-08-08 ] .

Paramedic education programs can be as short as 8 months or as long as 2 years. A associates degree program is 2 years, often administered through a community college. Degree programs are an option with two year associates degree programs being the standard four year bachelor degree programs exist. 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 to maintain their license or certification.

Paramedics are educated to evaluate and manage the acute stages of medical conditions. Special emphasis is placed on recognizing and treating potentially life-threatening conditions such as myocardial infarction (heart attack), stroke, respiratory distress, drug overdoses, traumatic injuries, childbirth and cardiac or respiratory arrest. Recently, many systems are beginning to aggressively treat non-life-threatening conditions, in order to increase patient comfort. For example, many systems are carrying medications used to treat nausea, or provide pain relief.

Specifically, paramedics are educated in airway management including intubation, pharmacologically assisted intubation, and increasingly rapid sequence induction; advanced cardiac life support including cardiac monitoring, 12-lead electrocardiograms, synchronized cardioversion and transcutaneous (through the skin) pacing; pediatric advanced life support; intravenous cannulation; intraosseous infusion; needle chest decompression; needle cricothyroidotomy; and the administration of a wide range of medications such as morphine sulfate and other opioids, benzodiazepines such as lorazepam, and dextrose.

In addition to state and national registry certifications, most paramedics are required to be certified in PALS (Pediatric Advanced Life Support), PPC (Pediatric Prehospital care) or PEPP (Pediatric Emergencies for the Prehospital Provider); PHTLS (Prehospital Trauma Life Support); ITLS (International Trauma Life Support); and ACLS (Advanced Cardiac Life Support). These additional requirements have education and certification from organizations such as the American Heart Association.

History

Prior to the 1970s, ambulances were staffed with advanced first-aid level responders who 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 Academy of Science's "White Paper" on motor vehicle fatalities and other accidents, which led to the creation of the National Highway Traffic Safety Administration, a concerted effort was undertaken to improve emergency medical care in the prehospital setting.

Jacksonville, Florida, Pittsburgh, Pennsylvania, Portland, Oregon and Seattle, Washington were among early pioneers in prehospital emergency medical training.

The Jacksonville Rescue Squad was organized in February, 1958 following the tragic death of a young boy in Elizabeth Lake. Police Chief Clyde R. Cook, realized the need for such a unit in Jacksonville.The majority of the members were uniformed members of the police and fire departments, civilians, and military personnel from Camp Lejeune and New River.Fact|date=April 2008

Pittsburgh's Freedom House paramedics are credited as the first EMT trainees in America. Pittsburgh's Peter Safar 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. [cite web|url=http://www.umc.pitt.edu/media/pcc040223/BHMS_freedom_house.html |title=Send Freedom House!|accessdate=2007-06-26 ] [cite news |title=Pitt Magazine |date=Spring, 2007 |pages=6 ] Dr. Eugene Nagel [cite web |url=http://www.zoominfo.com/people/Nagel_Eugene_3006219.aspx
title=Dr Eugene L. Nagel |accessdate=2007-08-06 ] trained City of Miami firefighters as the first US paramedics to use invasive techniques and portable defibrillators with telemetry in 1967. Baltimore's R. Adams Cowley, 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. Portland's Leonard Rose, M.D., in cooperation with Buck Ambulance Service, instituted a cardiac training program and began training 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 (LACoFD) also began training firefighters in emergency care. This was vividly portrayed in the television show, "Emergency!" which helped popularize the emergency medical service around the world.

James O. Page is often referred to as the father of fire department-based EMS because of his roles as the LACoFD chief in charge of the firefighter/paramedic program, the expert consultant for the show "Emergency!", and the founder of JEMS.

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

In 1972 the first civilian emergency medical helicopter transport service, Flight for Life opened in Denver, Colorado. Emergency medical helicopters or MEDEVACs were soon put into service elsewhere in the [http://www.krmc.org/ A.L.E.R.T.] Kalispell, Montana areas and soon the rest of 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).

The 1999 Columbine High School massacre served as a sentinel case highlighting the need to integrate tactical emergency medical support into law enforcement special operations.

ee also

* Paramedic
* Emergency Medical Technician
* Emergency Medical Services
* Flight for Life
* Flight Paramedic
* National Association of Emergency Medical Technicians
* National Registry of Emergency Medical Technicians
* Emergency medical responder levels by state

References

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External links

* [http://www.nremt.org National Registry of Emergency Medical Technicians]
* [http://www.nhtsa.dot.gov/portal/site/nhtsa/template.MAXIMIZE/menuitem.2a0771e91315babbbf30811060008a0c/?javax.portlet.tpst=4670b93a0b088a006bc1d6b760008a0c_ws_MX&javax.portlet.prp_4670b93a0b088a006bc1d6b760008a0c_viewID=detail_view&javax.portlet.begCacheTok=token&javax.portlet.endCacheTok=token&itemID=1822abcc80c81010VgnVCM1000002c567798RCRD&overrideViewName=Article US DOT National Standard Curriculum for EMT - First Responder/Basic/Intermediate/Paramedic]
* [http://www.medicschools.com Nationwide Directory of Paramedic Schools]