Paramedics in the United States

A paramedic is a highly trained medical professional who responds to and treats medical emergencies outside of a hospital. Paramedics provide medical treatment during transportation to an appropriate medical facility, usually an emergency department. Paramedics also treat conditions that do not require a hospital (e.g. giving a diabetic patient 50% dextrose in water). Paramedics derive the legal ability to provide advanced life support care through a medical doctor's license. In many ways, a paramedic is an extension to the services offered by a medical doctor.

In the United States of America, medical responders are classified as EMT-P (Paramedic), EMT-I (Intermediate), EMT-B (Basic), and First Responders. The paramedic is the most advanced EMT. Licensing is established by each state, and all 50 states have at least EMT-B and EMT-P ratings . Some states have additional classifications or use different titles (i.e. EMT-Cardiac, EMT-Cardiac Rescue Technician, EMT-Advanced, EMT-Shock Trauma).



Employment
Paramedics are employed by various public and private emergency service providers. These include private ambulance services, fire departments, the 9-1-1 system, hospitals, law enforcement agencies, the military, various EMS-specific, and "third service" public safety agencies. 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.

Critical care transporters move patients by ground ambulance or aircraft to a medical treatment facility. A nurse credentialled in critical care medicine may accompany the patient. Other critical care units use paramedics who have received critical care medical training, or continuing education courses in the Critical Care Emergency Medical Transport Program (CCEMTP).

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-the-Hospital paramedics are increasingly employed in the emergency departments and intensive care units due to the nursing shortage. Often, paramedics operate with greater latitude and autonomy than many nurses.

In the U.S., paramedic salaries can range from zero, for unpaid volunteer positions, to as much as $90,000 a year depending on location, experience, and supervisory responsibilities. It should be noted that volunteer paramedics can generally provide the same level of care as paid paramedics, commensurate with the local scope of practice.

Skills performed by paramedics

 * Follow American Heart Association Advanced Cardiac Life Support (ACLS) guidelines
 * Follow American Heart Association Pediatric Advanced Life Support (PALS) guidelines
 * Follow International Trauma Life Support (ITLS) or Pre-Hospital Trauma Life Support (PHTLS) guidelines

Education
The education and skills required of paramedics vary by state. The Department of Transportation 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 (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. A common associates degree program is 2 years, often taught through a community college. Regardless of educational path, all paramedic students must meet the same state requirements to take the certification exams, possibly including the National Registry exams. In addition, most locales require that paramedics attend ongoing refresher courses to maintain their license or certification.

In the field, the levels of training are separated into BLS (Basic Life Support), ILS (Intermediate Life Support) and ALS (Advanced Life Support) units. Basic-level skills include CPR, first aid, airway management, oxygen administration, spinal immobilization, traction splinting, bleeding control and splinting. Intermediate skills include IV therapy, endotracheal intubation and initial cardiac drug therapy. In addition to the basic and intermediate skills, the paramedic is also educated in EKG interpretation, advanced respiratory support and airway skills, RSI, pharmacology, trauma resuscitation, pediatric life support and advanced cardiac life support. Most states, and the National Registry, require ongoing continuing education and verification of clinical skills capability for a paramedic to maintain certification. A few states have permanent certification, except for issues involving gross negligence and malpractice.

Paramedics are educated to evaluate and manage the acute stages of medical conditions. Special emphasis is placed on recognizing and treating potentially life-treatening conditions such as myocardial infarction (heart attack), stroke, breathing problems, overdoses, traumatic injuries, and childbirth.

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 benzodiazepines such as lorazepam, opioids 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.

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. 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. Dr. Eugene Nagel 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 (LAFD) 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 LAFD 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 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.

Staffing
Much like the nursing shortage and the shortage of other health care professionals, there is a shortage of paramedics in some areas. Between the years 2002 and 2007, the need for paramedics has increased as more fire departments add paramedics cross-trained as firefighters. The educational requirements--about two years of education and training--and relatively low salary are pushing potential and current paramedics into other health care fields. The paramedic profession requires the same time and educational commitment as nursing, but tends to pay significantly less and provide far fewer job options outside of an EMS system.

Lack of Professional Equality
Paramedics can experience professional inequality in pay, job demands and prestige. Where state law and hospital policy allow, paramedics may work in hospital emergency departments or  intensive care units. Hospitals typically pay by credential, paying an EMT-P license less than a RN license, for the same job duties. Within the EMS system, job demands for paramedics vary by agency and geography. The workload of paramedics in a metropolitan city is more demanding than the workload in smaller towns, for example. Finally, the public and many health professionals generally view all EMT personnel in the same category. The accomplishment of attaining the highest certification within EMT ranks is often not recognized by the people a paramedic will serve.

Many health care systems tier paramedics as less skilled and less educated than nurses, despite this often being quite the opposite. Due to many factors, including call volume, extreme time constraints for treatment & transport (almost always occurring at the same time), and the lack of stable, sterile and safe environments that hospitals provide, the majority of paramedics are able to function and treat patients on a daily basis in situations that would test the abilities of many "In-Hospital" providers, including nurses and doctors.

Paramedics are exceptional at "street medicine" and improvisational treatment methods, that mainly are developed from experience working in low or no-light, tight spaces, environmental dangers such as unseen bodily fluids, chemicals & drugs, and severe weather conditions. They are highly adept at assessing patients using their own instincts and senses, augmented by their education and experience, a skill that many in-hospital providers lack due to a reliance on the highly advanced (and expensive) technology and equipment.

Many paramedics feel as though the general public - and other medical professionals - lack the respect or understanding of the capability and education of a paramedic. A large factor for this is political, as most health care systems are dominated by nurses unions and councils, who want to maintain their value, job options and pay rates, which would be threatened if paramedics were granted professional equality. Another factor for this perception is that prior to 1970 the paramedic, at least as currently defined, did not exist. Due to the relative infancy of paramedics as educated health care providers and not simple "ambulance drivers", they are often still seen as "clinicians" rather than true professionals. To still be viewed as an "ambulance driver" is a notion highly contested by and usually offensive to paramedics.

Currently, the only options available for a paramedic to "further" their career is to pursue a nursing or doctorate degree, to become an instructor, or to pursue government-level disaster management positions (such as in local or federal disaster agencies like FEMA ).

Fire Departments rarely provide a "career ladder" beyond lieutenant or captain within the department for paramedics unless they become cross trained as fire fighters. A key factor in the in-equality in the fire service between paramedics and traditional firefighters is the International Association of Fire-Fighters (IAFF) which many believe to have pushed its own labor based agenda (creation of jobs and expansion of fire departments) at the expense of the EMS profession as a whole.

Over Saturation
In large part to the push by the IAFF to staff every fire apparatus with paramedics, and public expectations to have a paramedic available on every call, more paramedics are performing fewer critical skills. While various organizations (mostly fire based) have denounced this phenomena, poor skill success rates have been documented.

By contrast, some systems believe that "less is more", notably Seattle's King County Medic One and  Boston EMS. Seattle saves more cardiac arrest patients (45%) with 1.48 paramedics per 10,000 residents. Boston has the second-highest survival rate (40%) and the lowest paramedics ratio at 0.86 . These systems emphasize providing basic life support training to more citizens and first reponders while retaining fewer, more experienced paramedics.

Ironically, this remains a hard sell to the public despite mounting scientific evidence, largely due to Union supported concept of "More is Better". Simply put, there are more paramedics in some systems than there are critical, or even emergent, patients. In days past a paramedic could count on getting enough intubations to stay proficient, but now seldom get more than 1 or 2 a year. This has resulted in decreased proficiency in critical skills, and has been attributed to increased mortality. Most of these systems have large numbers of paramedics with unwieldy, decentralized, or poor system integration.

Stress
EMT's and paramedics are vulnerable to job-related stress.

EMS professionals are unique among healthcare workers in that they operate independently, working in small, isolated teams to bring clinical intervention to uncontrolled and potentially dangerous environments. The mental and physical demands associated with this role can be especially taxing when coupled with the specter of trauma, tragedy and human suffering.

From the time of dispatch, the stage is set for tense conditions. A call to 911 creates a sudden need for a rapid motor vehicle response, and an all-around sense of urgency ensues with the clamor of radio calls and sirens. Paramedics are called upon to provide leadership and to render decisive medical intervention without delay.

As rescuers, paramedics are expected to have the emotional strength to maintain self-control in an emergency. As health care professionals, they must also be compassionate and empathetic to the psychological states of distraught bystanders and frightened patients. Treating sick or injured children is often ranked by paramedics as one of the most stressful parts of the job.

Paramedics also face the prospect of their own demise. EMS crews may be called to incidents that involve hazardous traffic conditions, treacherous rescue attempts, unstable surfaces, fire hazards, toxic substances, or weapons of mass destruction. Exposure to blood-born pathogens such as Hepatitis C, HIV/AIDS and tuberculosis from accidental needle punctures, blood sprays and coughing/spitting is an ever present risk that contributes to the overall sense of job-related danger.

Violent crime scenes can be another source of stress for paramedics. In the throes of an emergency call, EMS crews may find themselves operating on the scene of a crime with violent perpetrators still present and active. Consequently, in some high-crime urban EMS systems, paramedics and EMTs wear ballistic vests.

Stress persist while enroute to the hospital. With sirens blaring, paramedics scramble in the narrow confines of the patient care compartment to render emergency care while conveying critical information to emergency physicians by radio. The activity ends only after the sirens cease, with the delivery of the patient to a qualified ER staff.

As their adrenalin levels return to normal, paramedics face a degree of emotional vulnerability to unpleasant experiences. Paramedics exposed to especially traumatic situations may require special treatment sessions called "critical incident stress debriefing" to deal with the effects of emotional fatigue and to prevent burnout.

Political
While the history of firefighter paramedics is almost as long as the history of EMS itself, there is significant debate on what positive influence, if any, fire unions will have on EMS as a whole. In fact, the IAFF and other fire related organizations recently stopped an effort to make degrees mandatory at the national level for all new paramedics (similar to RNs), as well as blocking the formation of a National Emergency Medical Services Administration (NEMSA) similar to the National Fire Administration. While NEMSA would have unified the divisions of federal EMS support under one administration--opening up funding and standardization opportunities--it would have significantly detracted from the exploitation of EMS by the fire service. This effort was abandoned after several letters and much political lobbying by the political savvy IAFF and IAFC. Finally, less that 4% of non-fire based EMS received federal grant monies, the remaining going to fire-based EMS. Therefore the future role and the impact of fire-based EMS on the EMS profession is both heated, and vital, to the future of EMS.