User:EhJJ/Paramedic

The Star of Life is a symbol for emergency medical services.

A paramedic is a person who helps people who are hurt or ill. A paramedic finds out what is wrong, provides emergency therapy, and takes the hurt or ill person to the hospital.

The word "paramedic" can have different meanings in different places. In places, for example Canada and South Africa, the word is used by all people who work in the emergency medical services. In other places, for example the United States and the United Kingdom, the word can only be used by people who have special training and have passed the right exams. In the US and UK, not everyone who works with an ambulance is a paramedic, and some people don't know that.

The word paramedic comes from para- (auxiliary) +medical, meaning "related to medicine in an auxiliary capacity," the military paramedic, a parachuting medical corpsman, came later.

History of paramedicine

Early history

Paramedicine (what paramedics do) has developed from military conflicts. Imperial Roman Centaurions were the first to have a way of managing their hurt soldiers. When injured, the soldier would be moved from danger to a safe place and would have therapy, for example suturing wounds and completing amputations. In later wars, for example the Crusades, the Knights Hospitallers of the Order of St. John of Jerusalem did similar things. They are now know as St. John Ambulance.

The first ambulance was made during the Napoleonic War and was called the ambulance volante. It was created by Napoleon's Chief Surgeon, Baron Dominique Jean Larrey. This new horse-drawn carriage was used to transport the wounded rapidly to surgeons. These early ambulances were seen by the military as a general resource, and care of the wounded came second. It was common for ambulances to carrying ammunition to the battlefront, before they transported the wounded back. The basic design of ambulances did not change for nearly 100 years.

Early ambulance services

A system of first aid stations and field hospitals was used during the American Civil War. A network of ambulances, under the control of medical staff, made sure that patients were moved quickly to the best place for them to get care. Triage was also first used. The soldiers, after the war, took the same ideas and began to set up volunteer ambulance services in their home towns.

Not all places did this the same way. In Britain, ambulances were operated by the local hospital or police service. In Canada, the undertaker commonly had the only carriage that could move a person who had to lie down. In bigger cities, the ambulance service was done by the local health department, police or fire department.

People do not agree on when "ambulance attendants" (paramedics) were first formally trained. In the United States, it was probably in 1928 in Roanoke, Virginia. In Canada, it was probably 1889 in Toronto, Ontario. In the United Kingdom, it was probably even earlier.

As far as advanced skills, the military "medics" were the first to give medications like pain killers during the Second World War. Later, helicopters were used to move hurt soldiers to hospitals during the Korean War. It wasn't until much later that non-military paramedics were allowed to give medications or use helicopters.

Pre-hospital medicine

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 100 lbs.). 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.

Around 1966 in a published report entitled "Accidental Death and Disability: The Neglected Disease of Modern Society", (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. As a result, a series of grand experiments began in the United States. Almost simultaneously, and completely independent from one another, experimental programs began in three U.S. centers; Miami, Florida, Seattle, Washington, and Los Angeles, California, the first of these to go from being an experiment, to being a working unit, was in Los Angeles, with the passage of the Wedsworth-Townsend Act, other staes would soon push their own Paramedic bills through, and soon, every fire department in every major city in the country had their own paramedic squads. 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.

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 1972-1977, 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 6 paramedic units operating in 3 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, although in large measure, on a local level. In the broader scheme of things the term 'ambulance service' was replaced by 'emergency medical service' in order to reflect the change from a transportation system to a system which provided 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. In the U.S. the community college training model remains the most common, although university-based paramedic education models continue to evolve. These variations in both educational approaches and standards led to tremendous differences from one location to another, and at its worst, created a situation 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) 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 a EMT obtains certification through NREMT (NREMT-P, NREMT-I, NREMT-B), this is accepted by 40 of the 50 states in the United States. 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. 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 lever of training and skill than a 'Paramedic'.

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 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.

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 an Advanced 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 Advance 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 English 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 paramedicine 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., Australia, increasingly 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 practise 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 certified and licensed by a College of Paramedicine, created by legislation but run by the paramedics themselves. This body sets standards, conducts licensing exams, deals with complaints regarding individual practitioners, and consults the government with respect to legislation, policy, and regulations. Paramedics are governing and regulating themselves; 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).

In England, 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 federal 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 Capitol 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:

Treatment issue	Common technician skills	Paramedic/advanced technician skills	Advanced paramedic skills
Airway management	Manual and repositioning, Oro- and nasopharyngeal airway adjuncts, manual removal of obstructions, suctioning	endotracheal intubation (in some cases, naso as well), advanced airway management, ETT, LMA, ETOA, and combitube, deep suctioning, use of Magill forceps	Rapid sequence induction, surgical airways (including needle cricothyrotomy and others)
Breathing	Initial assessment (rate, effort, symmetry, skin color), obstructed airway maneuver, passive oxygen administration by nasal canula, rebreathing and non-rebreathing mask, active oxygen administration by Bag-Valve-Mask (BVM) device.	pulse oximetry, active oxygen administration by endotracheal tube or other device using BVM	Use of mechanical transport ventilators, active oxygen administration by surgical airway, decompression of chest cavity using needle/valve device (needle thoracotomy)
Circulation	Assessment of pulse (rate, rhythm, volume), blood pressure and capillary refill, patient positioning to enhance circulation, recognition and control of hemorrhage of all types using direct and indirect pressure and tourniquets	Ability to interpret assessment findings in terms of levels of perfusion, intravenous fluid replacement, vasoconstricting drugs	intravenous plasma volume expanders, blood transfusion, intraosseous (IO) cannulation (placement of needle into marrow space of a large bone), central venous access (central venous catheter by way of external jugular or subclavian)
Cardiac arrest	Cardiopulmonary resuscitation, airway management, manual ventilation with BVM, automatic external defibrillator	Dynamic resuscitation including intubation, drug administration (includes anti-arrhythmics), ECG interpretation (may be limited to Lead II) Semi-automatic or manual defibrillator	Expanded drug therapy options, ECG interpretation (12 Lead), manual defibrillator, synchronized mechanical or chemical cardioversion, external pacing of the heart
Cardiac Monitoring	Cardiac monitoring and interpretation of ECGs	12-lead ECG monitoring and interpretation	18-lead ECG monitoring and interpretation
Drug administration	Limited oral, limited aerosol, limited injection (usually IM)	Intramuscular, subcutaneous, intravenous injection (bolus), IV drip	per ETT, per rectal tube, per infusion pump
Drug types permitted	Low-risk/immediate requirements (e.g. ASA (chest pain), nitroglycerin (chest pain), oral glucose (diabetes), glucagon (diabetes), epinephrine (Allergic Reaction), ventolin (Asthma)). Note: Some jurisdictions also permit naloxone (Narcotic Overdose), nitrous oxide (for pain); considerable variation by jurisdiction	Considerable expansion of permitted drugs, but still typically limited to about 20, including analgesics (narcotic or otherwise) (for pain), antiarrhythmics (irregularities in heartbeat), major cardiac resuscitation drugs, bronchodilators (for breathing), vasoconstrictors (to improve circulation), sedatives	Dramatically expanded (up to 60) drug list, Note: In some jurisdictions advanced levels of paramedics are permitted to administer any drug, as long as they are familiar with it. Note: In some jurisdictions certain types of advanced paramedics have limited authority to prescribe.
Patient assessment	Basic physical assessment, 'vital' signs, history of general and current condition	More detailed physical assessment and history, auscultation, interpretation of assessment findings, ECG interpretation, glucometry, capnography, pulse oximetry	Interpretation of lab results, interpretation of chest x-rays, interpretation of cranial CT scan, limited medical diagnosis (e.g. rule out fracture using Ottawa Ankle Rules)
Wound management	Assessment, control of bleeding, application of pressure dressings and other types of dressings		Wound cleansing, wound closure with Steri-strips, suturing

Skills common to all EMTs and Paramedics

• Spinal injury management, including immobilization and safe transport.
• Fracture management, including assessment, splinting, 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, 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 individual medications vary widely, based on physician medical director preference, local standard of care, and law. These drugs may include Adenocard (Adenosine), which will slow the heart for a short period of time, and Atropine, which will speed 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 may also be permitted to perform rapid sequence inductionRSI, 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. Paramedics in some jurisdictions may also be permitted to sedate combative patients using antipsychotics like Haldol or Geodon. 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 which 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. 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. The material included here is, however, fairly typical and representative.

Different qualification levels across the world

United States

See the main article: Paramedics in the United States

A typical ambulance used in Waldorf, Maryland.

In the United States, there are 4 levels of emergency prehospital care defined by the U.S. Department of Transportation, which regulates prehospital emergency care education federally. From the most basic level to the most advanced, they are Medical First Responder, Emergency Medical Technician-Basic (EMT-B), Emergency Medical Technician-Intermediate (EMT-I), and Emergency Medical Technician-Paramedic (EMT-P). The paramedic is the most advanced level of EMT; however, in order to avoid confusion about the level of care, in practice the term "EMT" usually refers to Emergency Medical Technicians below the paramedic level. Official paramedic insignias and laws that designate level of care have codified this custom in many places. In the United States, paramedics working under the direction of emergency medical control physicians, provide the most advanced level of emergency medical care available to the general public outside of a hospital setting. Exceptions to this general statement include those physicians who sometimes operate with air ambulance services, and some jurisdictions with specially trained Critical Care Paramedic for inter-hospital critical care transfers.

Canada

See the main article: Paramedics in Canada

Canadian Ambulance

In most of Canada there are 3 levels of Paramedics: the Primary Care Paramedic with limited pharmaceutical protocols, the Advanced Care Paramedic with full ACLS qualification, and the Critical Care Transport Paramedic with very advanced qualifications. Several variations to this system occur in the City of Toronto and the province of Saskatchewan, which uses a four level model with Level I (Primary Care), Level II (Intermediate Care), Level III (Advanced Care) and Critical Care Transport Paramedics. It should also be noted that many Canadian jurisdictions do not use multiple levels of paramedics. There are many smaller and isolated communities which, for reasons of potential skills decay, medical control issues, or costs, operate with Primary Care Paramedics only. In Canada, paramedics provide the most advanced level of emergency medical care available to the general public outside of a hospital setting. Advanced Care and Critical Care Paramedics are able to perform more delegated medical acts than any other health professional besides physicians in the pre-hospital setting.

In a number of Canadian centres, paramedics are currently using a 12-Lead ECG to diagnose ST-Elevated Myocardial Infarction (STEMI), a specific type of heart attack. The experience of paramedics from the City of Ottawa with the use of this procedure was recently a topic of an article in the New England Journal of Medicine. Ottawa paramedics were the first paramedic service in Canada to have this STEMI protocol, which is now being implemented across the world, available to treat their patients.

Europe

In many parts of Europe a different paradigm is used for prehospital care, in which doctors, nurses and occasionally medical students function as pre-hospital providers, either in conjunction with or instead of paramedics. The following are two fairly representative examples illustrating the differing approach to the idea of paramedics in Europe.

France

See the main article: Paramedics in France

Paris Fire Dept. Ambulance

Paramedics, as we understand the role, do not exist in France. Within France, EMS is provided by means of an organization called a SAMU for each French Departement (county). Emergency response may be through the use of a fire department-based ambulance, such as the Paris Fire Department (www.pompiersparis.fr), or by an ambulance (labeled SAMU)staffed by a physician-led team (SMUR). The French philosophy is to provide more definitive care at the scene during life-threatening emergencies, and a SMUR team, consisting of a physician, a nurse, and an ambulance driver, may elect to conduct the majority of care, even resusctitation attempts, at the scene, prior to transport. SMUR teams are typically hospital-based. Since 1986, fire department-based ambulances have had the option of providing resuscitation service (reanimation) using specially-trained nurses, operating on protocols, in the role that we would normally expect to be performed by the paramedic. In actual practise, however, such units, and nurses, are extremely rare outside of the City of Paris. In France non-emergency and low-priority ambulance services are normally provided by private companies, with no formal requirements for the training of their staff.

Germany

See the main article: Paramedics in Germany

German Emergency Ambulance

In Germany, the closest role to that of paramedic is called Rettungassistent. Although there are others working in EMS in Germany, this is considered to be the only professional role, and the training of subordinate staff can vary greatly. The Rettungassistent is required to complete two years of training, the first consisting of theory classes at the post-secondary level, and hospital-based clinical experience. The second year consists of a 1,600 hour EMS-based preceptorship. At the conclusion of this training the Rettungassistent will have a skill set which is roughly similar to that of paramedics in many other countries, and will function as the crew chief on an emergency ambulance. One important difference, however, involves the manner in which EMS operates in Germany. In the German system it is much more common for emergency doctors (called Notarzt) to respond directly to high priority emergency calls. A Notarzt is a physician with additional training; although no specific medical specialty is required, the majority are anesthetists. The role of the Rettungassistent is to assist the Notarzt in the treatment of the patient; they may perform all of their advanced life support skills only under the direct supervision of the Notarzt. In exceptional circumstances, when there is an immediate threat to life, and when the Notarzt is not present, the Rettungassistent must be able to unilaterally perform all of their ALS skills. Not doing so places them in violation of federal German legislation (Handeln durch Unterlassen), however, federal law in German will normally provide the Rettungassistent with legal protection, under these extraordinary circumstances. (32,35 StGB)

Hong Kong

Ambulance of HKFSD

Hong Kong is currently progressing toward a system staffed with paramedics. Different from United Kingdom and Australia,ambulance service is run by Fire Services Department, Hong Kong.

• St. John Ambulance in Hong Kong A charitable organization with

a long history stretching back over a century and has been serving the community since 1884. In Hong Kong, the St. John Ambulance Association was established in 1884.It provides ambulance service,first aid and caring training course.

• Auxiliary Medical Service An independent government department

that trained, committed voluntary medical and health services provider in Hong Kong. Its mission is to supply effectively and efficiently regular services.

South Africa

See the main article: Emergency medical services in South Africa

All health practitioners in The Republic of South Africa are regulated by a standards generating body (SGB), the Health Professions Council of South Africa (HPCSA). The Department of Education has initiated the phasing out of short course training. This is to be replaced with a mid-level worker, and a prehospital clinician. The mid-level course is 2 years in duration, and exits on a level just above what many know as Intermediate Life Support (ILS), but below Advanced Life Support (ALS). They are placed on the Emergency Care Technician (ECT) register. The clinician qualification is a four year professional degree in Emergency Medical Care (Bachelor Emergency Medical Care), and is placed on the Emergency Care Practitioner (ECP) register. The only four institutions in the country to obtain the ECP qualification are the:

• University of Johannesburg
• Central University of Technology
• Durban University of Technology
• Cape Peninsula University of Technology

Australia

See the main article: Paramedics in Australia

Paramedics of the A.C.T. Ambulance Service

In Australia, the Paramedic Practitioner is a health care professional who responds to and treats all types of medical and trauma emergencies outside of a hospital setting before and during transportation to an appropriate medical facility. Paramedics also work in the inter-facility transport environment where a paramedic will continue or upgrade medical care to a higher level while transporting a patient from one healthcare facility to another. Under normal circumstances, paramedics transport patients to a hospital-based emergency department, however, this is not their only option. When it is clinically appropriate to do so, paramedics can also choose to treat patients requiring simple primary care or procedures in the out of the hospital setting, without the need to transport the patient to a hospital (e.g. a paramedic gives a diabetic patient 50% dextrose in water).

In Australia use of the professional title Paramedic is not restricted, registered or licensed. Prior to the 1990s most Paramedics had the professional title of Ambulance Officer. Recently there are various new professional titles depending on which state Ambulance Service you are employed by. Some titles include Paramedic, Paramedic Intern, Paramedic Specialist, Clinician, MICA Paramedic, Intensive Care Paramedic. Academia and publications relating to the profession in Australia are using the nomenclature Paramedic Practitioner.

Paramedic education depends on the entry requirements for employment by the state based Ambulance Service. Ambulance Victoria, SA Ambulance Service, Ambulance Service of NSW have Graduate entry programs. Students will undertake a three year pre-employment Bachelor degree in Health Science specializing as a Paramedic Practitioner. The degree title varies from each University. The Universities offering programs include Monash University, Victoria University, Flinders University, Charles Sturt University and Edith Cowan. On completion Students can apply for employment with there respective state Ambulance Service. After successfully meeting the entry requirements for employment the Student Paramedic will complete a twelve or twenty four month internship. Upon completion of the internship Students attain certification to practice as a Paramedic. The Paramedic Practitioner can then advance clinical status to Intensive Care Practitioner, or undertake specialised education and training in other fields for example rescue, aeromedicine. Another method is to apply for employment directly to the state Ambulance Service and undergo an internal Diploma of Health science program. This program will generally take up to three years to complete with the respective employer. The Ambulance Service of New South Wales and Queensland Ambulance Service offer this entry pathway. The Graduate pre-employment entry model is becoming popular, and there is a move by the Australian profession to continue this pathway.

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 England, 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. 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. Into the Breach offers an unusual opportunity to bear witness to unimaginable suffering, heroic stoicism, and the inventiveness of American EMS workers fighting to save lives.

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), 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.

See also

• Paramedics in Australia
• Paramedics in Canada
• Paramedics in France
• Paramedics in Germany
• Paramedics in the United States
• Paramedics in the United Kingdom
• National Association of Emergency Medical Technicians
• National Registry of Emergency Medical Technicians
• Flight Paramedic
• Critical Care Emergency Medical Transport Program

References

• American Heart Association (January 2006)
• Meisel, Zachary (2005-11-08). "Ding-a-Ling-a-Ling— Ambulances can be dangerous places". Slate. Washington Post. Newsweek Interactive Co. LLC. Retrieved 2007-01-25.
• "Tribute to R Adams Cowley, M.D." University of Maryland Medical Center. Retrieved 2005-12-30.
• US DOT "National Scope of Practice Model" (PDF). National Highway Traffic Safety Administration. Retrieved 2007-04-16.

External links

• National Registry of Emergency Medical Technicians
• National Association of Emergency Medical Technicians
• NHTSA Emergency Medical Services National Page