Paramedic

Throughout the evolution of pre-hospitalisation care, there has been an ongoing association with military conflict. One of the first indications of a formal process for managing injured people dates from the Imperial Legions of Rome, where aging Centurions, no longer able to fight, were given the task of organizing the removal of the wounded from the battlefield and providing some form of care. Such individuals, although not physicians, were probably among the world's earliest surgeons by default, being required to suture wounds and complete amputations. A similar situation existed in the Crusades, with the Knights Hospitaller of the Order of St. John of Jerusalem filling a similar function; this organisation continued, and evolved into what is now known throughout the Commonwealth of Nations as the St. John Ambulance and as the Order of Malta Ambulance Corps in the Republic of Ireland and various countries.

While civilian communities had organized ways to deal with prehospitalisation care and transportation of the sick and dying as far back as the bubonic plague in London between 1598 and 1665, such arrangements were typically ad hoc and temporary. In time, however, these arrangements began to formalize and become permanent. During the American Civil War, Jonathan Letterman devised a system of mobile field hospitals employing the first uses of the principles of triage. After returning home, some veterans began to attempt to apply what had they had seen on the battlefield to their own communities, and commenced the creation of volunteer life-saving squads and ambulance corps.

German Red Cross paramedics training in 1931

Ambulance of the Magen David Adom in Israel, 6 June 1948

These early developments in formalized ambulance services were decided at local levels, and this led to services being provided by diverse operators such as the local hospital, police, fire brigade, or even funeral directors who often possessed the only local transport allowing a passenger to lie down. In most cases these ambulances were operated by drivers and attendants with little or no medical training, and it was some time before formal training began to appear in some units. An early example was the members of the Toronto Police Ambulance Service receiving a mandatory five days of training from St. John as early as 1889.[10]

Prior to World War I motorized ambulances started to be developed, but once they proved their effectiveness on the battlefield during the war the concept spread rapidly to civilian systems. In terms of advanced skills, once again the military led the way. During World War II and the Korean War battlefield medics administered painkilling narcotics by injection in emergency situations, and pharmacists' mates on warships were permitted to do even more without the guidance of a physician. The Korean War also marked the first widespread use of helicopters to evacuate the wounded from forward positions to medical units, leading to the rise of the term "medevac". These innovations would not find their way into the civilian sphere for nearly twenty more years.

By the early 1960s experiments in improving medical care had begun in some civilian centres. One early experiment involved the provision of pre-hospital cardiac care by physicians in Belfast, Northern Ireland, in 1966.[11] This was repeated in Toronto, Canada in 1968 using a single ambulance called Cardiac One, which was staffed by a regular ambulance crew, along with a hospital intern to perform the advanced procedures. While both of these experiments had certain levels of success, the technology had not yet reached a sufficiently advanced level to be fully effective; for example, the Toronto portable defibrillator and heart monitor was powered by lead-acid car batteries, and weighed around 45 kilograms (99 lb).

EMTs caring for a collapsed woman in New York

In 1966, a report called Accidental Death and Disability: The Neglected Disease of Modern Society—commonly known as The White Paper—was published in the United States. This paper presented data showing that soldiers who were seriously wounded on the battlefields during the Vietnam War had a better survival rate than individuals who were seriously injured in motor vehicle accidents on California's freeways.[12] Key factors contributing to victim survival in transport to definitive care such as a hospital were identified as comprehensive trauma care, rapid transport to designated trauma facilities, and the presence of medical corpsmen who were trained to perform certain critical advanced medical procedures such as fluid replacement and airway management.

As a result of The White Paper, the US government moved to develop minimum standards for ambulance training, ambulance equipment and vehicle design. These new standards were incorporated into Federal Highway Safety legislation and the states were advised to either adopt these standards into state laws or risk a reduction in Federal highway safety funding. The "White Paper" also prompted the inception of a number of emergency medical service (EMS) pilot units across the US including paramedic programs. The success of these units led to a rapid transition to make them fully operational.

Freedom House Ambulance Service was the first civilian emergency medical service in the United States to be staffed by paramedics, most of whom were black. New York City's Saint Vincent's Hospital developed the United States' first Mobile Coronary Care Unit (MCCU) under the medical direction of William Grace, MD, and based on Frank Pantridge's MCCU project in Belfast, Northern Ireland. In 1967, Eugene Nagle, MD and Jim Hirschmann, MD helped pioneer the United States' first EKG telemetry transmission to a hospital and then in 1968, a functional paramedic program in conjunction with the City of Miami Fire Department. In 1969, the City of Columbus Fire Services joined with the Ohio State University Medical Center to develop the "HEARTMOBILE" paramedic program under the medical direction of James Warren, MD and Richard Lewis, MD. In 1969, the Haywood County (NC) Volunteer Rescue Squad developed a paramedic program (then called Mobile Intensive Care Technicians) under the medical direction of Ralph Feichter, MD. In 1969, the initial Los Angeles paramedic training program was instituted in conjunction with Harbor General Hospital, now Harbor–UCLA Medical Center, under the medical direction of J. Michael Criley, MD and James Lewis, MD. In 1969, the Seattle "Medic 1" paramedic program was developed in conjunction with the Harborview Medical Center under the medical direction of Leonard Cobb, MD. The Marietta (GA) initial paramedic project was instituted in the Fall of 1970 in conjunction with Kennestone Hospital and Metro Ambulance Service, Inc. under the medical direction of Luther Fortson, MD.[13] The Los Angeles County and City established paramedic programs following the passage of The Wedsworth-Townsend Act in 1970. Other cities and states passed their own paramedic bills, leading to the formation of services across the US. Many other countries also followed suit, and paramedic units formed around the world.

In the military, however, the required telemetry and miniaturization technologies were more advanced, particularly due to initiatives such as the space program. It would take several more years before these technologies drifted through 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 sometimes still operate, in European countries and Latin America.

While doing background research at Los Angeles' UCLA Harbor Medical Center for a proposed new show about doctors, television producer Robert A. Cinader, working for Jack Webb, happened to encounter "firemen who spoke like doctors and worked with them". This concept developed into the television series Emergency!, which ran from 1972 to 1977, portraying the exploits of this new profession called paramedics. The show gained popularity with emergency services personnel, the medical community, and the general public. When the show first aired in 1972, there were just six paramedic units operating in three pilot programs in the whole of the US, and the term paramedic was essentially unknown. By the time the program ended in 1977, there were paramedics operating in all fifty states. The show's technical advisor, James O. Page, was a pioneer of paramedicine and responsible for the UCLA paramedic program; he would go on to help establish paramedic programs throughout the US, and was the founding publisher of the Journal of Emergency Medical Services (JEMS). The JEMS magazine creation resulted from Page's previous purchase of the PARAMEDICS International magazine. Ron Stewart, the show's medical director, was instrumental in organizing emergency health services in southern California earlier in his career during the 1970s, in the paramedic program in Pittsburgh, and had a substantial role in the founding of the paramedic programs in Toronto and Nova Scotia, Canada.

Throughout the 1970s and 1980s, the paramedic field continued to evolve, with a shift in emphasis from patient transport to treatment both on scene and en route to hospitals. This led to some services changing their descriptions from "ambulance services" to "emergency medical services".

Bicycle paramedics in Los Angeles indicate the changing nature of the job.

The training, knowledge-base, and skill sets of both paramedics and emergency medical technicians (EMTs) were typically determined by local medical directors based primarily on the perceived needs of the community along with affordability. There were also large differences between localities 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 up to university level education. This emphasis on increasing qualifications has followed the progression of other health professions such as nursing, which also progressed from on the job training to university level qualifications.

The variations in educational approaches and standards required for paramedics has led to large differences in the required qualifications between locations—both within individual countries and from country to country. Within the UK training is a three-year course equivalent to a bachelor's degree. Comparisons have been made between Paramedics and nurses; with nurses now requiring degree entry (BSc) the knowledge deficit is large between the two fields. This has led to many countries passing laws to protect the title of "paramedic" (or its local equivalent) from use by anyone except those qualified and experienced to a defined standard. This usually means that paramedics must be registered with the appropriate body in their country; for example all paramedics in the United Kingdom must by registered with the Health and Care Professions Council (HCPC) in order to call themselves a paramedic. In the United States, a similar system is operated by the National Registry of Emergency Medical Technicians (NREMT), although this is only accepted by forty of the fifty states.

As paramedicine has evolved, a great deal of both the curriculum and skill set has existed in a state of flux. Requirements often originated and evolved at the local level, and were based upon the preferences of physician advisers and medical directors. Recommended treatments would change regularly, often changing more like a fashion than a scientific discipline. Associated technologies also rapidly evolved and changed, with medical equipment manufacturers having to adapt equipment that worked inadequately outside of hospitals, to be able to cope with the less controlled pre-hospital environment.

Physicians began to take more interest in paramedics from a research perspective as well. By about 1990, the fluctuating trends began to diminish, being replaced by outcomes-based research. This research then drove further evolution of the practice of both paramedics and the emergency physicians who oversaw their work, with changes to procedures and protocols occurring only after significant research demonstrated their need and effectiveness (an example being ALS). Such changes affected everything from simple procedures such as CPR, to changes in drug protocols. As the profession grew, some paramedics went on to become not just research participants, but researchers in their own right, with their own projects and journal publications. In 2010, the American Board of Emergency Medicine created a medical subspecialty for physicians who work in emergency medical services.[14]

Changes in procedures also included the manner in which the work of paramedics was overseen and managed. In the early days medical control and oversight was direct and immediate, with paramedics calling into a local hospital and receiving orders for every individual procedure or drug. While this still occurs in some jurisdictions, it has become increasingly rare. Day-to-day operations largely moved from direct and immediate medical control to pre-written protocols or standing orders, with the paramedic typically seeking advice after the options in the standing orders had been exhausted.

Firefighters assist while paramedics from the Toronto Paramedic Services load a patient into an ambulance.

While the evolution of paramedicine described above is focused largely on the US, many other countries followed a similar pattern, although often with significant variations. Canada, for example, attempted a pilot paramedic training program at Queen's University, Kingston, Ontario, in 1972. The program, which intended to upgrade the then mandatory 160 hours of training for ambulance attendants, was found to be too costly and premature. The program was abandoned after two years, and it was more than a decade before the legislative authority for its graduates to practice was put into place. An alternative program which provided 1,400 hours of training at the community college level prior to commencing employment was then tried, and made mandatory in 1977, with formal certification examinations being introduced in 1978. Similar programs occurred at roughly the same time in Alberta and British Columbia, with other Canadian provinces gradually following, but with their own education and certification requirements. Advanced Care Paramedics were not introduced until 1984, when Toronto trained its first group internally, before the process spread across the country. By 2010 the Ontario system involved a two-year community college based program, including both hospital and field clinical components, prior to designation as a Primary Care Paramedic, although it is starting to head towards a university degree-based program. The province of Ontario announced that by September 2021, the entry level primary care paramedic post-secondary program would be enhanced from a two-year diploma to a three-year advanced diploma in primary care paramedicine. Resultantly, advanced care paramedics in Ontario will require a minimum of four years of post-secondary education and critical care paramedics will require five years of post-secondary education.

In Israel, paramedics are trained in either of the following ways: a three-year degree in Emergency Medicine (B.EMS), a year and three months IDF training, or MADA training. Paramedics manage and provide medical guidelines in mass casualty incidents. They operate in MED evac and ambulances. They are legalized under the 1976 Doctors Ordinance (Decree). In a 2016 study at the Ben Gurion University of the Negev it was found that 73% of trained paramedics stop working within a five-year period, and 93% stop treating within 10 years.[15]

In the United Kingdom, ambulances were originally municipal services after the end of World War II. Training was frequently conducted internally, although national levels of coordination led to more standardization of staff training. Ambulance services were merged into county-level agencies in 1974, and then into regional agencies in 2006. The regional ambulance services, most often trusts, are under the authority of the National Health Service and there is now a significant standardization of training and skills.

The UK model has three levels of ambulance staff. In increasing order of clinical skill these are: emergency care assistants, ambulance technicians and paramedics.

The original route to becoming a paramedic was to join an NHS ambulance service and work towards the position from non-emergency patient transport roles through to the emergency division as a Qualified Ambulance Man/Woman and after qualifying those who wanted to increase their knowledge and skills joined the Association of Emergency Medical Technicians. This was an organisation run by members to promote and train Paramedics. The AEMT was supported by BASICS and large numbers of hospital doctors. Training took place at various locations in members off duty time and at their expense. Trainees followed a wide academic curriculum which led to a written exam. If successful they became Associates and entered the clinical phase of training. Attending hospitals they were trained in all the practical skills. The final examination was designed to put as much pressure on the candidate as possible. The hospital consultant would sign to say that he was happy for a passing candidate to treat their family.

In the 1970s some ambulance service training departments started offering advanced skill training under the direction of Peter Baskett (Consultant Anaesthetist at Frenchay Hospital, Bristol) and Douglas Chamberlain (Consultant Cardiologist in Brighton). This was the inception of the paramedic service in the UK, and subsequently was developed across Europe. In 1986 the NHSTA introduced the certificate in Extended Ambulance Aid. Existing AEMT Paramedics were forced to sit a conversion examination. The curriculum for the new qualification was substantially smaller cutting out a lot of anatomy and physiology as well as pharmacology and obstetrics. In November 1986 the examinations took place with the first certificates issued alphabetically. The candidate with highest score received certificate 177 and was the only Paramedic at Huntingdon. Training was introduced the following year but due to costs the time was kept to a minimum. The AEMT folded in the 1990s as the training offered was no longer recognised by the ambulance services. Equipment owned by the branches was given to hospitals.

The NHS Training Authority, NHSTA, (which became the NHS Training Directorate and then the NHS Training Division, which in turn became the Institute of Health and Care Development. The institute was acquired by the Edexcel examination board in 1998, and Edexcel was acquired by Pearson in 2004. Pearson continued to operate the IHCD 'brand' until 2016. This 'in-house' paramedic training was a modular programme, usually between 10 and 12 weeks, followed by time spent in a hospital emergency department, coronary care centre and operating theatre, assisting the anaesthetist and performing airway management techniques such as endotracheal intubation. Completion of the course allowed the paramedic to register with the Council for Professions Supplementary to Medicine (CPSM), which was superseded by the Health and Care Professions Council (HCPC), a regulatory body. It is worth noting that this route also took around 3 years if undertaken as quickly as possible. After the non emergency training, initially an 8-week clinical technician course was undertaken, with 750 mentored hours. Staff usually had to be a qualified technician for 2 years before applying for paramedic training noted above, a further 750 hours mentored had to be undertaken to complete the paramedic course to practice and demonstrate the skills learnt during the hospital placements and residential course.

Prior to regulation and closure of the title, the term "paramedic" was used by a variety of people with varying levels of ability. Paramedics could apply to register via a grandfather scheme which ended in 2002.

However, university qualifications are expected for paramedics, with the entry level being an Honours Bachelor of Science degree in Pre-Hospital Care or Paramedic Science. As the title "Paramedic" is legally protected, those utilising must be registered with the Health and Care Professions Council (HCPC),[16] and in order to qualify for registration you must meet the standards for registration, which include having a degree obtained through an approved course.[17][18]

It is common for paramedics to have master's degrees in Advanced practice or Paramedic practice and is indeed a requisite for paramedic prescribing.

Paramedics work in various settings including NHS and Independent Ambulance Providers, Air Ambulances, Emergency Departments and other alternative settings. Some paramedics have gone on to become Paramedic Practitioners, a role that practices independently in the pre-hospital environment in a capacity similar to that of a nurse practitioner. This is a fully autonomous role, and such senior paramedics are now working in hospitals, community teams such as rapid response teams, and also in increasing numbers in general practice, where their role includes acute presentations, complex chronic care and end of life management. They work as part of the allied health professional team including Doctors, Nurses, physician Associates, Physiotherapists, Associate Physicians, Health Care Assistant and Clinical Pharmacists. Paramedic Practitioners also undertake examinations modelled upon the MRCGP (a combination of applied knowledge exams, clinical skills and work place based assessment) in order to use the title "specialist". There are also now a growing number of these advanced paramedics who are independent and supplementary prescribers. There are also 'Critical Care Paramedics' who specialise in acute emergency incidents. In 2018, the UK government changed legislation allowing Paramedics to independently prescribe,[19] which will open new pathways to Paramedics to progress into. This came into force on 1 April 2018, but did not immediately affect practice as guidance was still being written.[20]

In the United States, the minimum standards for paramedic training is considered vocational, but many colleges offer paramedic associate degree or bachelor's degree options. Paramedic education programs typically follow the U.S. NHTSA EMS Curriculum, DOT or National Registry of EMTs.[21] While many regionally accredited community colleges offer paramedic programs and two-year associate degrees, a handful of universities also offer a four-year bachelor's degree component.[22] The national standard course minimum requires didactic and clinical hours for a paramedic program of 1,500 or more hours of classroom training and 500+ clinical hours to be accredited and nationally recognized.[23][24] Calendar length typically varies from 12 months to upwards of two years, excluding degree options, EMT training, work experience, and prerequisites. It is required to be a certified Emergency Medical Technician prior to starting paramedic training.[25] Entry requirements vary, but many paramedic programs also have prerequisites such as one year required work experience as an emergency medical technician, or anatomy and physiology courses from an accredited college or university. Paramedics in some states must attend up to 50+ hours of ongoing education, plus maintain Pediatric Advanced Life Support and Advanced Cardiac Life Support. National Registry requires 70 + hours to maintain its certification or one may re-certify through completing the written computer based adaptive testing again (between 90 and 120 questions) every two years.

Paramedicine continues to grow and evolve into a formal profession in its own right, complete with its own standards and body of knowledge, and in many locations paramedics have formed their own professional bodies.[26] The early technicians with limited training, performing a small and specific set of procedures, has become a role beginning to require a foundation degree in countries such as Australia, South Africa, the UK, and increasingly in Canada and parts of the U.S. such as Oregon, where a degree is required for entry level practice.[27]

As a part of Emergency Medicine Reform in 2017 Ministry of Healthcare introduced two specialties — "paramedic" and "emergency medical technician".[28] A paramedic is a person with at least junior bachelor degree in "Healthcare" field. For a person with basic nine-year school education, the term of training is four years (junior bachelor's degree equivalent); with 11 years of schooling - two years for junior bachelor or 3–4 years for bachelor's degrees.[28]

While there are varying degrees of training and expectations around the world, a set of skills practiced by paramedics in the pre-hospital setting commonly includes:[30]

• Advanced cardiac life support, or ACLS, including cardiopulmonary resuscitation, defibrillation, cardioversion, transcutaneous pacing, and administration of cardiac drugs
• Patient assessment, including acquisition of vital signs, physical exam, chest auscultation, history taking, electrocardiogram acquisition and interpretation, capnography, pulse oximetry, point-of-care ultrasound and basic blood chemistry interpretation (glucose, lactate)
• Airway management techniques including tracheal intubation, cricothyrotomy, rapid sequence induction, supraglottic airway insertion, manual repositioning, sterile suctioning, use of oropharyngeal and nasopharyngeal airway adjuncts, and manual removal of obstructions via direct laryngoscopy and use of magill forceps
• Thorocostomy and pericardiocentesis to relieve pneumothorax and pericardial tamponade
• Intravenous (IV) and intraosseous (IO) cannulation
• Oxygen administration and positive pressure ventilation via bag-valve-mask, CPAP device, or ventilator
• Fluid resuscitation
• Administration of emergency drugs/medications (see section below)
• Bleeding control and management of shock
• Spinal injury management, including immobilization and safe transport
• Fracture management, including assessment, splinting, and dislocation reduction
• Obstetrics, including assessment, childbirth, and recognition of and procedures for obstetrical emergencies such as breech presentation, cord presentation, and placental abruption
• Management of burns, including classification, estimate of surface area, recognition of more serious burns, and treatment
• Triage of patients in a mass casualty incident
• Surgical procedures such as field amputation, escharotomy, or thorocotomy[31] (if trained and credentialed)

Paramedics carry and administer a wide array of emergency medications. The specific medications they are permitted to administer vary widely, based on local standards of care and protocols. For an accurate description of permitted drugs or procedures in a given location, it is necessary to contact that jurisdiction directly. A representative list of medications may commonly include:

A paramedic preparing an intravenous infusion for a patient

• Analgesic medications such as aspirin, ketorolac and paracetamol (acetaminophen), used to relieve pain or decrease nausea and vomiting
• Narcotics like morphine, pethidine, fentanyl, and methoxyflurane, used to treat severe pain.
• Beta and calcium channel blockers such as diltiazem, metoprolol and verapamil used to slow down excessively high heart rates or severe hypertension
• Parasympatholytic drug such as Atropine, also known as anticholinergic drugs, used to speed up slow bradycardic heart rates
• Sympathomimetics[32] such as dopamine, dobutamine, norepinephrine, and epinephrine used for cardiac arrest, severe hypotension (low blood pressure), shock and sepsis. These are often known as "vasoactive" agents.
• Dextrose (often D50W, a solution of 50% dextrose in water), used to treat hypoglycemia (low blood sugar)
• Sedatives like midazolam, lorazepam, etomidate, and ketamine[33][34] used to reduce the irritability or agitation of patients, to relieve symptoms of seizure, or provide procedural sedation
• Paralytics such as succinylcholine, rocuronium, and vecuronium, used when an emergency procedure such as rapid sequence intubation (RSI) is required[35]
• Antipsychotics like haloperidol or ziprasidone, used to sedate combative patients
• Respiratory medications such as albuterol and ipratropium bromide used to treat conditions such as asthma and acute bronchitis
• Steroids such as hydrocortisone and methylprednisolone used to treat inflammatory respiratory conditions and adrenal crisis
• Cardiac medications such as nitroglycerin and aspirin are used to treat cardiac ailments such as angina and myocardial infarctions
• Diuretic medications such as furosemide to treat congestive heart failure and severe hypertension
• Antiarrhythmics such as amiodarone, adenosine, lidocaine and magnesium sulfate used to treat abnormal heart rhythms such as ventricular tachycardia and ventricular fibrillation
• Antiemetics such as promethazine or ondansetron used for nausea and vomiting
• Antidotes for a variety of toxins such as naloxone (opioids), pralidoxime (organophosphates), sodium bicarbonate (tricyclic antidepressants), and hydroxocobalamin (cyanide).
• Blood products and tranexamic acid in cases of hemorrhagic shock
• Broad spectrum antibiotics such as ceftriaxone or vancomycin for cases of sepsis
• Hormones like oxytocin to control post-partum bleeding

As described above, many jurisdictions have different levels of paramedic training, leading to variations in what procedures different paramedics may perform depending upon their qualifications. Three common general divisions of paramedic training are the basic technician, general paramedic or advanced technician, and advanced paramedic. Common skills that these three certification levels may practice are summarized in the table below. The skills for the higher levels automatically also assume those listed for lower levels.