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Paramedics in the United States

In the United States, the paramedic is a allied health professional whose primary focus is to provide advanced emergency medical care for patients who access Emergency Medical Services (EMS). This individual possesses the complex knowledge and skills necessary to provide patient care and transportation. Paramedics function as part of a comprehensive EMS response under physician medical direction. Paramedics often serve in a prehospital role, responding to Public safety answering point (9-1-1) calls in an ambulance. The paramedic serves as the initial entry point into the health care system. A standard requirement for state licensure involves successful completion of a nationally accredited Paramedic program at the certificate or associate degree level.[1]

Star of Life

History edit

Prior to 1970, ambulances were staffed with advanced first-aid level responders who were frequently referred to as "ambulance attendants." There was little regulation or standardized training for those staffing these early emergency response vehicles or the required equipment carried inside. Around 1966 in a published report entitled "Accidental Death and Disability: The Neglected Disease of Modern Society",[2] (known in EMS trade as the White Paper) medical researchers began to reveal, to their astonishment, that soldiers who were seriously wounded on the battlefields of Vietnam had a better survival rate than those individuals who were seriously injured in motor vehicle accidents on California freeways. Early research attributed these differences in outcome to a number of factors, including comprehensive trauma care, rapid transport to designated trauma facilities, and a new type of medical corpsman; one who was trained to perform certain critical advanced medical procedures such as fluid replacement and airway management, which allowed the victim to survive the journey to definitive care.

 
Paramedics traveling to a patient in an ambulance

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

Other communities in the United States were also experimenting with advanced emergency medical care. Pittsburgh's branch of Freedom House paramedics are credited as the first emergency medical technician (EMT) trainees in the United States. Pittsburgh's Peter Safar is referred to as the father of CPR.[6] In 1967, he began training unemployed African-American men in what later became Freedom House Ambulance Service,[7][8] the first paramedic squadron in the United States.[9][10] Almost simultaneously, and completely independent from one another, experimental programs began in three U.S. centers; Miami, Florida; Seattle, Washington; and Los Angeles, California. Each was aimed at determining the effectiveness of using firefighters to perform many of these same advanced medical skills in the pre-hospital setting in the civilian world. Many in the senior administration of the fire departments were initially quite opposed to this concept of 'firemen giving needles', and actively resisted and attempted to cancel pilot programs more than once. In Seattle, the Medic One program at Harborview Medical Center and the University of Washington Medical Center, started by Leonard Cobb, M.D., began training firefighters in CPR in 1970.[11] Dr. Eugene Nagel trained city of Miami firefighters as the first U.S. paramedics to use invasive techniques and portable defibrillators with telemetry in 1967.[12] Dr. Jonathan Wasserberger helped actualize the teaching curriculum associated with this innovative training in 1973.[13][14][15]

Elsewhere, the novel approach to pre-hospital care was also evolving. Portland's Leonard Rose, M.D., in cooperation with Buck Ambulance Service, instituted a cardiac training program and began training other paramedics. Baltimore's R. Adams Cowley,[16] the father of trauma medicine, devised the concept of integrated emergency care, designing the first civilian Medevac helicopter program and campaigning for a statewide EMS system. Other communities that were early participants in the development of paramedicine included Jacksonville, Florida, Pittsburgh, Pennsylvania (in an expanded program), and Seattle, Washington (in an expanded program). In 1972 the first civilian emergency medical helicopter transport service, Flight for Life opened in Denver, Colorado.[17] Emergency medical helicopters were soon put into service elsewhere in the United States. It is now routine to have paramedic and nurse-staffed EMS helicopters in most major metropolitan areas. The vast majority of these aeromedical services are utilized for critical care air transport (inter-hospital) in addition to emergency medical services (pre-hospital).

A television producer, working for producer Jack Webb,[18] of Dragnet and Adam-12 fame, was in Los Angeles' UCLA Harbor Medical Center, doing background research for a proposed new TV show about doctors, when he happened to encounter these 'firemen who spoke like doctors and worked with them'. This novel idea would eventually evolve into the Emergency! television series, which ran from 1972–1977, portraying the exploits of a new group called 'paramedics'. The show captured the imagination of emergency services personnel, the medical community, and the general public. When the show first aired in 1972, there were only 6 full-fledged paramedic units operating in 3 pilot programs (Miami, Los Angeles, Seattle) in the whole of the United States. No one had ever heard the term 'paramedic'; indeed, it is reported that one of the show's actors was initially concerned that the 'para' part of the term might involve jumping out of airplanes! By the time the program ended production in 1977, there were paramedics operating in every state. The show's technical advisor was a pioneer of paramedicine, James O. Page,[19] then a Battalion Chief responsible for the Los Angeles County Fire Department 'paramedic' program, but who would go on to help establish other paramedic programs in the U.S., and to become the founding publisher of the Journal of Emergency Medical Services.[20]

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

Physicians began to take more interest in paramedics from a research perspective as well. By about 1990, most of the 'trendiness' in pre-hospital emergency care had begun to disappear, and was replaced by outcome-based research and evidence-based medicine;[21] the gold standard for the rest of medicine. This research began to drive the evolution of the practice of both paramedics and the emergency physicians who oversaw their work; changes to procedures and protocols began to occur only after significant outcome-based research demonstrated their need. Paramedics became increasingly accountable for their errors as well, and these too led to changes in procedure.[22] Such changes affected everything from simple procedures, such as CPR, to changes in drug protocols and other advanced procedures.[23] 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.

Education edit

The education and skills required of paramedics vary by state. The U.S. National Highway Traffic Safety Administration (NHTSA) designs and specifies a National Standard Curriculum[24] 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.[25] 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.[26]

 
Paramedics in training

Paramedic education programs can be as short as six months or as long as four years. An associate degree program is two years, often administered through a community college. Degree programs are an option, with two-year associate degree programs being most common, although four-year bachelor's degree programs exist. In contrast to Commonwealth countries such as Canada, the United Kingdom, Australia and New Zealand, generally the minimum education is a two- to three-year degree at an accredited college or university for the entry-level paramedic, with four-year or even graduate degrees becoming the preferred credential in such jurisdictions. Many paramedic programs in the United States are through adult career and technical schools that provide a certificate of completion upon completion of the program. All programs must meet the current national standard curriculum. The institutions offering such training vary greatly across the country in terms of programs and requirements, and each must be examined by the prospective student in terms of both content and requirements where they hope to practice.[27]

Regardless of education, all students must meet the same state requirements to take the certification exams, including the National Registry exams which consist of a psychomotor skills practical examination and a Computer Based Testing (CBT). In addition, most locales require that paramedics attend ongoing refresher courses and continuing medical education to maintain their license or certification. In addition to state and national registry certifications, most paramedics are required to be certified in pediatric advanced life support, pediatric prehospital care or pediatric emergencies for the prehospital provider, prehospital trauma life support; international trauma life support, and advanced cardiac life support. These additional requirements have education and certification from organizations such as the American Heart Association.

Credentialling and oversight edit

In the U.S., the community college training model remains the most common, although some university-based paramedic education models exist. These variations in both educational approaches and standards has led to tremendous differences from one location to another. There may be situations in which a group of people with 120 hours of training, and another group (in another jurisdiction) with university degrees, were both calling themselves 'paramedics'. There were some efforts made to resolve these discrepancies. The National Association of Emergency Medical Technicians (NAEMT) along with National Registry of Emergency Medical Technicians (NREMT)[28] attempted to create a national standard by means of a common licensing examination, but to this day, this has never been universally accepted by U.S. States, and issues of licensing reciprocity for paramedics continue, although if an EMT obtains certification through NREMT (NREMT-P, NREMT-I, NREMT-B), this is accepted by 40 of the 50 states in the United States.[29] This confusion was further complicated by the introduction of complex systems of gradation of certification, reflecting levels of training and skill, but these too were, for the most part, purely local. To clarify, at least at a national level, the National Highway Traffic Safety Administration (NHTSA), which is the federal organization with authority to administer the EMS system, defines the various titles given to prehospital medical workers based on the level of care they provide. They are EMT-P (Paramedic), EMT-I (Intermediate), EMT-B (Basic), and First Responders. While providers at all levels are considered emergency medical technicians, the term "paramedic" is most properly used in the United States to refer only to those providers who are EMT-P's. Apart from this distinction, the only truly common trend that would evolve was the relatively universal acceptance of the term 'emergency medical technician' being used to denote a lower level of training and skill than a 'paramedic'.

Changes in procedures also included the manner in which the work of paramedics was overseen and managed. In the earliest days of the field, medical control and oversight was direct and immediate, with paramedics calling into a local hospital and receiving orders for every individual procedure or drug.[30] 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.[31] Medical oversight became driven more by chart review or rounds, than by step by step control during each call.

Scope of practice edit

In the United States there are no federal guidelines for the scope of practice for any level of EMS provider. In the field, paramedics follow a set of pre-approved procedures and interventions for particular scenarios. For example, all fifty states allow for the administration of some form of anti-convulsive.[32] In the state of Massachusetts a paramedic may administer the anti-convulsant, midazolam, up to a maximum of 6 mg .[33] While in Maine paramedics are allowed to administer midazolam in upwards of 10 mg boluses.[34] These pre-approved procedures are known as standing orders. Standing orders cannot surpass a provider's scope of practice. Scopes of practice represent the degree to which providers are trained.[35]

The following is derived NHTSA's "National EMS Scope of Practice model". Without federal mandate, each state's office of emergency medical services may alter their respective standing orders. The purpose of the model is to provide a guide toward standardization in patient care that both improves patient outcomes but allows for reciprocity between states.[36] Prior to certification as a paramedic, candidates must be a certified EMT. Traditionally, a paramedic is allowed to perform all skills an EMT may perform.[37]

Below are some of the key skills and procedures expected of a paramedic in the United States.[38]

Key skills and procedures edit

Medications edit

One of the primary differences between emergency medical technicians and paramedics includes the breadth and number of medications paramedic ambulances typically carry. Due to the variation between each state EMS office it would be cumbersome and unrealistic to list each and every single medication paramedics carry across the United States.[43] Instead, different medications are carried to serve similar patient-care scenarios. Most services carry medications like albuterol or ipratropium to alleviate bronchospasm during an acute asthma attack.[44] They carry cardiac medications to reverse deadly heart rhythms like amiodarone and lidocaine.[45] They can also use medications like atropine, adenosine and different types of beta-blockers as heart rate controls.[46][47] Paramedics may also utilize a number of other medications for analgesia, such as antiemetics and anti-convulsants.[48] In the setting of inter-facility transfers providers may continue the administration of other medications that are not typically carried in the field (Heparin, Blood products, Potassium).

Variations in scope edit

The aforementioned skills and medications are often standing orders in state protocols. The expectations and responsibilities of providers varies across state lines. There are instances where special waivers granted by states allowing paramedic services to go beyond their protocols.[49] For example, some paramedics in New Hampshire may be allowed to perform a surgical cricothyrotomy, medics in Virginia are allowed to use ultrasound as a diagnostic technique and paramedics in Arizona are allowed to perform rapid-sequence intubation utilizing paralytic and sedating medication to completely control a patient's airway.[50][51][52]

Employment edit

Paramedics are employed by various public and private emergency service providers. These include private ambulance services, fire departments, public safety or police departments, hospitals, law enforcement agencies, the military, and municipal EMS agencies in addition to and independent from police or fire departments, also known as a 'third service'. Paramedics may respond to medical incidents in an ambulance, rescue vehicle, helicopter, fixed-wing aircraft, motorcycle, or fire suppression apparatus.


Paramedics may also be employed in medical fields that do not involve transportation of patients. Such positions include offshore drilling platforms, phlebotomy, blood banks, research labs, educational fields, law enforcement and hospitals.[53]

Aside from their traditional roles, paramedics may also participate in one of many specialty arenas:

  • Critical care transporters move patients by ground ambulance or aircraft between medical treatment facilities. This may be done to allow a patient to receive a higher level of care in a more specialized facility. Registered Nurses with training in Emergency Nursing may work with paramedics in these settings. Paramedics participating in this role generally also provide care not traditionally administered by Paramedics who respond to 911 calls. Examples of this are blood transfusions, intra-aortic balloon pumps, and mechanical ventilators.[54]
  • 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.[55] The advantage to having dual role paramedics is that medical care is provided almost immediately.
  • Hospital paramedics are sometimes employed in either of the outpatient and inpatient areas. Emergency departments employ the largest number of paramedics working inside of hospitals. Considered ambulatory care, emergency departments are classified as an outpatient area of a hospital. Depending on their scope of practice and job description within the emergency department, paramedics are allowed to triage and assess incoming patients, provide analysis and interpretation of both labs and EKGs, intravenous therapy, drug administration, transportation of emergency department patients to diagnostic testing or their inpatient rooms. Paramedics are also employed indirectly in the inpatient areas of hospitals as well. Paramedics are utilized in intensive care units assisting other licensed staff with ICU patients and they are utilized on high risk transport teams by providing transportation, continuation of care and assisting in sedation of patients during minimally invasive and invasive procedures at the bedside and in diagnostic areas. Because of the nature and purpose of these teams, paramedics work closely with radiology, interventional radiology, nuclear medicine and anesthesiology.

Salary edit

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

See also edit

References edit

  1. ^ "National EMS Scope of Practice Model" (PDF). ems.gov. NHTSA. February 2007.
  2. ^ National Research Modern Society (2000). Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, D.C: National Academies Press. ISBN 978-0-309-07532-9.
  3. ^ Chawkins, Steve (October 28, 2015). "Walter S. Graf dies at 98; cardiologist helped launch paramedic system". Los Angeles Times. Retrieved 24 November 2015.
  4. ^ "Our History". UCLA Center for Prehospital Care. 8 October 2014. Retrieved 24 November 2015.
  5. ^ "Dr. Walter Graf, 1917-2015". UCLA Center for Prehospital Care. 20 October 2015. Retrieved 24 November 2015.
  6. ^ Grenvik A, Kochanek PM (February 2004). "The incredible career of Peter J. Safar, MD: the Michelangelo of acute medicine". Critical Care Medicine. 32 (2 Suppl): S3–7. doi:10.1097/01.CCM.0000110733.48596.4F. PMID 15043225.
  7. ^ Karns, Jameson (2015-11-05). (magazine) "Paramedics of Freedom House: Empowerment Through Paramedicine". {{cite journal}}: Check |url= value (help); Cite journal requires |journal= (help)
  8. ^ "Freedom House". Retrieved 2008-11-07.
  9. ^ . Archived from the original on September 1, 2006. Retrieved 2007-06-26.
  10. ^ "Pitt Magazine". Spring 2007. p. 6.
  11. ^ "Cobb Honored as one of Resuscitation Greats". Retrieved 2008-11-07.
  12. ^ Nagel, E. L. (1970-10-12). "Telemetry-medical command in coronary and other mobile emergency care systems". JAMA: The Journal of the American Medical Association. 214 (2): 332–338. doi:10.1001/jama.214.2.332. ISSN 0098-7484. PMID 5469072.
  13. ^ Wasserberger, J. (1974). "The EMT's Training and Future." In Findeiss, C.J. (ed). Emergency Medical Care, Symposia Specialists. New York, International Medical Book Corp., 297-304
  14. ^ Wasserberger, Jonathan; Eubanks, David H. (1977). Advanced Paramedic Procedures: A Practical Approach. Saint Louis: The C.V. Mosby Company. ISBN 0-8016-5351-7.
  15. ^ Wasserberger, Jonathan; Eubanks, David H. (1981). Practical Paramedic Procedures. St. Louis: The C.V. Mosby Company. ISBN 0-8016-5353-3.
  16. ^ "Tribute to R. Adams Cowley". Retrieved 2008-11-07.
  17. ^ "Flight for Life Colorado website". Retrieved 2008-11-07.
  18. ^ "Jack Webb (Museum of Broadcast Communications website)". Retrieved 2008-11-07.
  19. ^ "Fire and EMS Service Icon James O. Page Passes Away". Retrieved 2008-11-07.
  20. ^ . Archived from the original on 2008-08-01. Retrieved 2008-11-07.
  21. ^ Sackett, David L; Rosenberg, William M C; Gray, J A Muir; Haynes, R Brian; Richardson, W Scott (1996-01-13). "Evidence based medicine: what it is and what it isn't". British Medical Journal. 312 (7023): 71–72. doi:10.1136/bmj.312.7023.71. PMC 2349778. PMID 8555924.
  22. ^ Meisel, Zachary (2005-11-08). "Ding-a-Ling-a-Ling". Slate. Retrieved 2008-06-14.
  23. ^ Burton, John H (June 2006). "Out-of-Hospital Endotracheal Intubation: Half Empty or Half Full?". Annals of Emergency Medicine. 47 (6): 542–544. doi:10.1016/j.annemergmed.2006.01.023. PMID 16713781.
  24. ^ "National Standard Curriculum". Retrieved 2007-08-08.
  25. ^ "National Standard Curriculum". Retrieved 2008-11-07.
  26. ^ "State Office Information". Retrieved 2012-11-11.
  27. ^ "Nationwide Directory of Paramedic Schools". Retrieved 2008-11-07.
  28. ^ "NREMT website". Retrieved 2011-09-17.
  29. ^ "Reciprocity Information (NREMT website)". Retrieved 2011-09-17.
  30. ^ Kuehl, Alexander (2002). Prehospital systems and medical oversight. Dubugue, Iowa: Kendall/Hunt Pub. ISBN 978-0-7872-7071-1.
  31. ^ Victoria L. Fedor; Jacob L. Hafter (2003). EMS and the Law. Sudbury, Mass: Jones & Bartlett Publishers. ISBN 978-0-7637-2068-1.
  32. ^ Kupas, Douglas F.; Schenk, Ellen; Sholl, J. Matthew; Kamin, Richard (2015-04-03). "Characteristics of Statewide Protocols for Emergency Medical Services in the United States". Prehospital Emergency Care. 19 (2): 292–301. doi:10.3109/10903127.2014.964891. ISSN 1090-3127. PMID 25689221. S2CID 10494952.
  33. ^ EMERGENCY MEDICAL SERVICES PRE-HOSPITAL STATEWIDE TREATMENT PROTOCOLS. Massachusetts: Massachusetts Office of Emergency Medical Services. 2020. pp. appendix A, pg 10.
  34. ^ "Pre-Hospital Care Protocols | Maine Emergency Medical Services". www.maine.gov. Retrieved 2021-03-01.
  35. ^ National Association of State EMS Officials. National EMS Scope of Practice Model 2019 (Report No. DOT HS 812-666). Washington, DC: National Highway Traffic Safety Administration. pp 20.
  36. ^ National EMS Scope of Practice Model (PDF). The National Highway Traffic Safety Administration.
  37. ^ "Paramedic Candidate Handbook" (PDF). National Registry of Emergency Medical Technicians. 2019.
  38. ^ "National Registered Paramedics | National Registry of Emergency Medical Technicians". nremt.org. Retrieved 2021-02-21.
  39. ^ American Academy of Orthopaedic Surgeons (2017). Nancy Caroline's Emergency Care in the Streets (8th ed.). Burlington, MA: Jones & Bartlett Learning. pp. 501–505. ISBN 978-1-284-14405-5. OCLC 1003284719.
  40. ^ National Assoc. of Emergency Medical Technicians (2017). AMLS : Advanced Medical Life Support (2nd ed.). Burlington, MA: Jones & Bartlett Learning. p. 7. ISBN 978-1-284-04092-0. OCLC 915774812.
  41. ^ Andolsek, Christopher M. (2013). Intravenous Therapy for Prehospital Providers. Mike Kennamer, American Academy of Orthopaedic Surgeons (2nd ed.). Burlington, MA: Jones & Bartlett Learning. ISBN 978-1-4496-4158-0. OCLC 854239961.
  42. ^ American Academy of Orthopaedic Surgeons (2017). Nancy Caroline's Emergency Care in the Streets. Nancy L. Caroline (8th ed.). Burlington, MA: Jones & Bartlett Learning. pp. 965–969, 1024–1026. ISBN 978-1-284-14405-5. OCLC 1003284719.
  43. ^ Friese, Greg (2019). "How to buy EMS drugs for your department". EMS1. Retrieved 2021-02-21.
  44. ^ American Academy of Orthopaedic Surgeons (2017). Nancy Caroline's emergency care in the streets. Nancy L. Caroline (8th ed.). Burlington, MA: Jones & Bartlett Learning. p. 941. ISBN 978-1-284-14405-5. OCLC 1003284719.
  45. ^ "Advanced Cardiac Life Support Algorithms". cpr.heart.org. 2020. Retrieved 2021-02-21.
  46. ^ "Adult Tachycardia with a Pulse Algorithm". cpr.heart.org. 2020. Retrieved 2021-02-21.
  47. ^ "Adult Bradycardia with a Pulse Algorithm". cpr.heart.org. 2021. Retrieved 2021-02-21.
  48. ^ American Academy of Orthopaedic Surgeons (2017). Nancy Caroline's Emergency Care in the Streets. Nancy L. Caroline (8th ed.). Burlington, MA: Jones & Bartlett Learning. p. 656. ISBN 978-1-284-14405-5. OCLC 1003284719.
  49. ^ "Advisories, memos, and notices for OEMS | Mass.gov". www.mass.gov. Retrieved 2021-02-21.
  50. ^ NH Bureau of EMS (2015). "Surgical Cricothyrotomy Bougie Assisted Prerequisite Protocol" (PDF). nh.gov.
  51. ^ Calams, Sarah (2019). "Why point-of-care ultrasound should be a mainstay in EMS". EMS1. Retrieved 2021-02-21.
  52. ^ Arizona Department of Health Services (2015). "Recommendations for Paramedic Performance of Rapid Sequence Intubation (RSI) in the Prehospital EMS Environment" (PDF).
  53. ^ (PDF). Archived from the original (PDF) on 2006-12-17. Retrieved 2008-11-10.
  54. ^ (PDF). Archived from the original (PDF) on 2008-10-01. Retrieved 2008-11-10.
  55. ^ (PDF). Archived from the original (PDF) on 2011-07-21. Retrieved 2008-11-10.
  • National Academy of Sciences and National Research Council. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, D.C.: The National Academies Press, 1966.

Further reading edit

  • Hazzard, Kevin (2022). American Sirens: The Incredible Story of the Black Men Who Became America's First Paramedics. New York: Hachette Books. ISBN 9780306926075. OCLC 1291313033.

External links edit

  • National Association of Emergency Medical Technicians homepage
  • National Registry of Emergency Medical Technicians
  • NHTSA Emergency Medical Services national page
  • Paramedicine.com

paramedics, united, states, united, states, paramedic, allied, health, professional, whose, primary, focus, provide, advanced, emergency, medical, care, patients, access, emergency, medical, services, this, individual, possesses, complex, knowledge, skills, ne. In the United States the paramedic is a allied health professional whose primary focus is to provide advanced emergency medical care for patients who access Emergency Medical Services EMS This individual possesses the complex knowledge and skills necessary to provide patient care and transportation Paramedics function as part of a comprehensive EMS response under physician medical direction Paramedics often serve in a prehospital role responding to Public safety answering point 9 1 1 calls in an ambulance The paramedic serves as the initial entry point into the health care system A standard requirement for state licensure involves successful completion of a nationally accredited Paramedic program at the certificate or associate degree level 1 Star of Life Contents 1 History 2 Education 3 Credentialling and oversight 4 Scope of practice 4 1 Key skills and procedures 4 2 Medications 4 3 Variations in scope 5 Employment 6 Salary 7 See also 8 References 9 Further reading 10 External linksHistory editPrior to 1970 ambulances were staffed with advanced first aid level responders who were frequently referred to as ambulance attendants There was little regulation or standardized training for those staffing these early emergency response vehicles or the required equipment carried inside Around 1966 in a published report entitled Accidental Death and Disability The Neglected Disease of Modern Society 2 known in EMS trade as the White Paper medical researchers began to reveal to their astonishment that soldiers who were seriously wounded on the battlefields of Vietnam had a better survival rate than those individuals who were seriously injured in motor vehicle accidents on California freeways Early research attributed these differences in outcome to a number of factors including comprehensive trauma care rapid transport to designated trauma facilities and a new type of medical corpsman one who was trained to perform certain critical advanced medical procedures such as fluid replacement and airway management which allowed the victim to survive the journey to definitive care nbsp Paramedics traveling to a patient in an ambulanceDuring the 1960s a Los Angeles cardiologist named Walter S Graf became concerned about the lack of actual medical care being given to coronary patients during emergency transportation to a hospital In 1969 while serving as president of the Los Angeles Chapter of the American Heart Association he created a mobile critical care unit consisting of a Chevy van a registered nurse and a portable defibrillator 3 The same year his patient Kenneth Hahn a member of the Los Angeles County Board of Supervisors persuaded the Supervisors to approve a pilot program to train county firefighters as Mobile Intensive Care Paramedics A change in state law was necessary to allow personnel other than doctors and nurses to render emergency medical care Hahn recruited two state legislators who wrote the Wedworth Townsend Paramedic Act of 1970 signed into law by Governor Ronald Reagan on July 15 1970 despite opposition from doctors nurses and attorneys Paramedic training began the next month at the Freeman Memorial Hospital under Graf s direction 4 It was the first nationally accredited paramedic training program in the United States 5 Other communities in the United States were also experimenting with advanced emergency medical care Pittsburgh s branch of Freedom House paramedics are credited as the first emergency medical technician EMT trainees in the United States Pittsburgh s Peter Safar is referred to as the father of CPR 6 In 1967 he began training unemployed African American men in what later became Freedom House Ambulance Service 7 8 the first paramedic squadron in the United States 9 10 Almost simultaneously and completely independent from one another experimental programs began in three U S centers Miami Florida Seattle Washington and Los Angeles California Each was aimed at determining the effectiveness of using firefighters to perform many of these same advanced medical skills in the pre hospital setting in the civilian world Many in the senior administration of the fire departments were initially quite opposed to this concept of firemen giving needles and actively resisted and attempted to cancel pilot programs more than once In Seattle the Medic One program at Harborview Medical Center and the University of Washington Medical Center started by Leonard Cobb M D began training firefighters in CPR in 1970 11 Dr Eugene Nagel trained city of Miami firefighters as the first U S paramedics to use invasive techniques and portable defibrillators with telemetry in 1967 12 Dr Jonathan Wasserberger helped actualize the teaching curriculum associated with this innovative training in 1973 13 14 15 Elsewhere the novel approach to pre hospital care was also evolving Portland s Leonard Rose M D in cooperation with Buck Ambulance Service instituted a cardiac training program and began training other paramedics Baltimore s R Adams Cowley 16 the father of trauma medicine devised the concept of integrated emergency care designing the first civilian Medevac helicopter program and campaigning for a statewide EMS system Other communities that were early participants in the development of paramedicine included Jacksonville Florida Pittsburgh Pennsylvania in an expanded program and Seattle Washington in an expanded program In 1972 the first civilian emergency medical helicopter transport service Flight for Life opened in Denver Colorado 17 Emergency medical helicopters were soon put into service elsewhere in the United States It is now routine to have paramedic and nurse staffed EMS helicopters in most major metropolitan areas The vast majority of these aeromedical services are utilized for critical care air transport inter hospital in addition to emergency medical services pre hospital A television producer working for producer Jack Webb 18 of Dragnet and Adam 12 fame was in Los Angeles UCLA Harbor Medical Center doing background research for a proposed new TV show about doctors when he happened to encounter these firemen who spoke like doctors and worked with them This novel idea would eventually evolve into the Emergency television series which ran from 1972 1977 portraying the exploits of a new group called paramedics The show captured the imagination of emergency services personnel the medical community and the general public When the show first aired in 1972 there were only 6 full fledged paramedic units operating in 3 pilot programs Miami Los Angeles Seattle in the whole of the United States No one had ever heard the term paramedic indeed it is reported that one of the show s actors was initially concerned that the para part of the term might involve jumping out of airplanes By the time the program ended production in 1977 there were paramedics operating in every state The show s technical advisor was a pioneer of paramedicine James O Page 19 then a Battalion Chief responsible for the Los Angeles County Fire Department paramedic program but who would go on to help establish other paramedic programs in the U S and to become the founding publisher of the Journal of Emergency Medical Services 20 Throughout the 1970s and 1980s the field continued to evolve although in large measure on a local level In the broader scheme of things the term ambulance service was replaced by emergency medical service to reflect the change from a transportation system to a system that provides actual medical care The training knowledge base and skill sets of both paramedics and emergency medical technicians both competed for the job title and EMT Paramedic was a common compromise were typically determined by what local medical directors were comfortable with what it was felt that the community needed and what could actually be afforded There were also tremendous local differences in the amount and type of training required and how it would be provided This ranged from in service training in local systems through community colleges and ultimately even to universities During the evolution of paramedicine a great deal of both curriculum and skill set was in a state of constant flux Permissible skills evolved in many cases at the local level and were based upon the preferences of physician advisers and medical directors Treatments would go in and out of fashion and sometimes back in again The use of certain drugs Bretylium for example illustrate this In some respects the development seemed almost faddish Technologies also evolved and changed and as medical equipment manufacturers quickly learned the pre hospital environment was not the same as the hospital environment equipment standards that worked fine in hospitals could not cope well with the less controlled pre hospital environment Physicians began to take more interest in paramedics from a research perspective as well By about 1990 most of the trendiness in pre hospital emergency care had begun to disappear and was replaced by outcome based research and evidence based medicine 21 the gold standard for the rest of medicine This research began to drive the evolution of the practice of both paramedics and the emergency physicians who oversaw their work changes to procedures and protocols began to occur only after significant outcome based research demonstrated their need Paramedics became increasingly accountable for their errors as well and these too led to changes in procedure 22 Such changes affected everything from simple procedures such as CPR to changes in drug protocols and other advanced procedures 23 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 Education editThe education and skills required of paramedics vary by state The U S National Highway Traffic Safety Administration NHTSA designs and specifies a National Standard Curriculum 24 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 25 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 26 nbsp Paramedics in trainingParamedic education programs can be as short as six months or as long as four years An associate degree program is two years often administered through a community college Degree programs are an option with two year associate degree programs being most common although four year bachelor s degree programs exist In contrast to Commonwealth countries such as Canada the United Kingdom Australia and New Zealand generally the minimum education is a two to three year degree at an accredited college or university for the entry level paramedic with four year or even graduate degrees becoming the preferred credential in such jurisdictions Many paramedic programs in the United States are through adult career and technical schools that provide a certificate of completion upon completion of the program All programs must meet the current national standard curriculum The institutions offering such training vary greatly across the country in terms of programs and requirements and each must be examined by the prospective student in terms of both content and requirements where they hope to practice 27 Regardless of education all students must meet the same state requirements to take the certification exams including the National Registry exams which consist of a psychomotor skills practical examination and a Computer Based Testing CBT In addition most locales require that paramedics attend ongoing refresher courses and continuing medical education to maintain their license or certification In addition to state and national registry certifications most paramedics are required to be certified in pediatric advanced life support pediatric prehospital care or pediatric emergencies for the prehospital provider prehospital trauma life support international trauma life support and advanced cardiac life support These additional requirements have education and certification from organizations such as the American Heart Association Credentialling and oversight editIn the U S the community college training model remains the most common although some university based paramedic education models exist These variations in both educational approaches and standards has led to tremendous differences from one location to another There may be situations in which a group of people with 120 hours of training and another group in another jurisdiction with university degrees were both calling themselves paramedics There were some efforts made to resolve these discrepancies The National Association of Emergency Medical Technicians NAEMT along with National Registry of Emergency Medical Technicians NREMT 28 attempted to create a national standard by means of a common licensing examination but to this day this has never been universally accepted by U S States and issues of licensing reciprocity for paramedics continue although if an EMT obtains certification through NREMT NREMT P NREMT I NREMT B this is accepted by 40 of the 50 states in the United States 29 This confusion was further complicated by the introduction of complex systems of gradation of certification reflecting levels of training and skill but these too were for the most part purely local To clarify at least at a national level the National Highway Traffic Safety Administration NHTSA which is the federal organization with authority to administer the EMS system defines the various titles given to prehospital medical workers based on the level of care they provide They are EMT P Paramedic EMT I Intermediate EMT B Basic and First Responders While providers at all levels are considered emergency medical technicians the term paramedic is most properly used in the United States to refer only to those providers who are EMT P s Apart from this distinction the only truly common trend that would evolve was the relatively universal acceptance of the term emergency medical technician being used to denote a lower level of training and skill than a paramedic Changes in procedures also included the manner in which the work of paramedics was overseen and managed In the earliest days of the field medical control and oversight was direct and immediate with paramedics calling into a local hospital and receiving orders for every individual procedure or drug 30 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 31 Medical oversight became driven more by chart review or rounds than by step by step control during each call Scope of practice editThis section may require cleanup to meet Wikipedia s quality standards No cleanup reason has been specified Please help improve this section if you can March 2012 Learn how and when to remove this template message In the United States there are no federal guidelines for the scope of practice for any level of EMS provider In the field paramedics follow a set of pre approved procedures and interventions for particular scenarios For example all fifty states allow for the administration of some form of anti convulsive 32 In the state of Massachusetts a paramedic may administer the anti convulsant midazolam up to a maximum of 6 mg 33 While in Maine paramedics are allowed to administer midazolam in upwards of 10 mg boluses 34 These pre approved procedures are known as standing orders Standing orders cannot surpass a provider s scope of practice Scopes of practice represent the degree to which providers are trained 35 The following is derived NHTSA s National EMS Scope of Practice model Without federal mandate each state s office of emergency medical services may alter their respective standing orders The purpose of the model is to provide a guide toward standardization in patient care that both improves patient outcomes but allows for reciprocity between states 36 Prior to certification as a paramedic candidates must be a certified EMT Traditionally a paramedic is allowed to perform all skills an EMT may perform 37 Below are some of the key skills and procedures expected of a paramedic in the United States 38 Key skills and procedures edit Assessment and evaluation of general incident scene safety Triage of patients in a mass casualty incident Patient primary and secondary assessments 39 40 Effective verbal and written reporting skills Documentation Carrying Lifting Extrication of patients Peripheral intravenous cannulation 41 Cardiac monitoring and manual defibrillation 42 ECG acquisition and interpretation Orotracheal intubation Medications edit One of the primary differences between emergency medical technicians and paramedics includes the breadth and number of medications paramedic ambulances typically carry Due to the variation between each state EMS office it would be cumbersome and unrealistic to list each and every single medication paramedics carry across the United States 43 Instead different medications are carried to serve similar patient care scenarios Most services carry medications like albuterol or ipratropium to alleviate bronchospasm during an acute asthma attack 44 They carry cardiac medications to reverse deadly heart rhythms like amiodarone and lidocaine 45 They can also use medications like atropine adenosine and different types of beta blockers as heart rate controls 46 47 Paramedics may also utilize a number of other medications for analgesia such as antiemetics and anti convulsants 48 In the setting of inter facility transfers providers may continue the administration of other medications that are not typically carried in the field Heparin Blood products Potassium Variations in scope edit The aforementioned skills and medications are often standing orders in state protocols The expectations and responsibilities of providers varies across state lines There are instances where special waivers granted by states allowing paramedic services to go beyond their protocols 49 For example some paramedics in New Hampshire may be allowed to perform a surgical cricothyrotomy medics in Virginia are allowed to use ultrasound as a diagnostic technique and paramedics in Arizona are allowed to perform rapid sequence intubation utilizing paralytic and sedating medication to completely control a patient s airway 50 51 52 Employment editParamedics are employed by various public and private emergency service providers These include private ambulance services fire departments public safety or police departments hospitals law enforcement agencies the military and municipal EMS agencies in addition to and independent from police or fire departments also known as a third service Paramedics may respond to medical incidents in an ambulance rescue vehicle helicopter fixed wing aircraft motorcycle or fire suppression apparatus Paramedics may also be employed in medical fields that do not involve transportation of patients Such positions include offshore drilling platforms phlebotomy blood banks research labs educational fields law enforcement and hospitals 53 Aside from their traditional roles paramedics may also participate in one of many specialty arenas Critical care transporters move patients by ground ambulance or aircraft between medical treatment facilities This may be done to allow a patient to receive a higher level of care in a more specialized facility Registered Nurses with training in Emergency Nursing may work with paramedics in these settings Paramedics participating in this role generally also provide care not traditionally administered by Paramedics who respond to 911 calls Examples of this are blood transfusions intra aortic balloon pumps and mechanical ventilators 54 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 55 The advantage to having dual role paramedics is that medical care is provided almost immediately Hospital paramedics are sometimes employed in either of the outpatient and inpatient areas Emergency departments employ the largest number of paramedics working inside of hospitals Considered ambulatory care emergency departments are classified as an outpatient area of a hospital Depending on their scope of practice and job description within the emergency department paramedics are allowed to triage and assess incoming patients provide analysis and interpretation of both labs and EKGs intravenous therapy drug administration transportation of emergency department patients to diagnostic testing or their inpatient rooms Paramedics are also employed indirectly in the inpatient areas of hospitals as well Paramedics are utilized in intensive care units assisting other licensed staff with ICU patients and they are utilized on high risk transport teams by providing transportation continuation of care and assisting in sedation of patients during minimally invasive and invasive procedures at the bedside and in diagnostic areas Because of the nature and purpose of these teams paramedics work closely with radiology interventional radiology nuclear medicine and anesthesiology Salary editThe salary of a paramedic in the US varies The mean average is 30 000 with the lowest 10 earning under 20 000 and the top 10 earning over 50 000 considerably less than the salaries of paramedics in Canada Factors such as education and location of the paramedic s practice influence the salary Paramedic supervisors and managers may make between 60 000 80 000 depending on location See also editFlight Paramedic Emergency medical responder levels by state United States Air Force Pararescue Emergency medical services in the United StatesReferences edit National EMS Scope of Practice Model PDF ems gov NHTSA February 2007 National Research Modern Society 2000 Accidental Death and Disability The Neglected Disease of Modern Society Washington D C National Academies Press ISBN 978 0 309 07532 9 Chawkins Steve October 28 2015 Walter S Graf dies at 98 cardiologist helped launch paramedic system Los Angeles Times Retrieved 24 November 2015 Our History UCLA Center for Prehospital Care 8 October 2014 Retrieved 24 November 2015 Dr Walter Graf 1917 2015 UCLA Center for Prehospital Care 20 October 2015 Retrieved 24 November 2015 Grenvik A Kochanek PM February 2004 The incredible career of Peter J Safar MD the Michelangelo of acute medicine Critical Care Medicine 32 2 Suppl S3 7 doi 10 1097 01 CCM 0000110733 48596 4F PMID 15043225 Karns Jameson 2015 11 05 magazine Paramedics of Freedom House Empowerment Through Paramedicine a href Template Cite journal html title Template Cite journal cite journal a Check url value help Cite journal requires journal help Freedom House Retrieved 2008 11 07 Send Freedom House Archived from the original on September 1 2006 Retrieved 2007 06 26 Pitt Magazine Spring 2007 p 6 Cobb Honored as one of Resuscitation Greats Retrieved 2008 11 07 Nagel E L 1970 10 12 Telemetry medical command in coronary and other mobile emergency care systems JAMA The Journal of the American Medical Association 214 2 332 338 doi 10 1001 jama 214 2 332 ISSN 0098 7484 PMID 5469072 Wasserberger J 1974 The EMT s Training and Future In Findeiss C J ed Emergency Medical Care Symposia Specialists New York International Medical Book Corp 297 304 Wasserberger Jonathan Eubanks David H 1977 Advanced Paramedic Procedures A Practical Approach Saint Louis The C V Mosby Company ISBN 0 8016 5351 7 Wasserberger Jonathan Eubanks David H 1981 Practical Paramedic Procedures St Louis The C V Mosby Company ISBN 0 8016 5353 3 Tribute to R Adams Cowley Retrieved 2008 11 07 Flight for Life Colorado website Retrieved 2008 11 07 Jack Webb Museum of Broadcast Communications website Retrieved 2008 11 07 Fire and EMS Service Icon James O Page Passes Away Retrieved 2008 11 07 Journal of Emergency Medical Services website Archived from the original on 2008 08 01 Retrieved 2008 11 07 Sackett David L Rosenberg William M C Gray J A Muir Haynes R Brian Richardson W Scott 1996 01 13 Evidence based medicine what it is and what it isn t British Medical Journal 312 7023 71 72 doi 10 1136 bmj 312 7023 71 PMC 2349778 PMID 8555924 Meisel Zachary 2005 11 08 Ding a Ling a Ling Slate Retrieved 2008 06 14 Burton John H June 2006 Out of Hospital Endotracheal Intubation Half Empty or Half Full Annals of Emergency Medicine 47 6 542 544 doi 10 1016 j annemergmed 2006 01 023 PMID 16713781 National Standard Curriculum Retrieved 2007 08 08 National Standard Curriculum Retrieved 2008 11 07 State Office Information Retrieved 2012 11 11 Nationwide Directory of Paramedic Schools Retrieved 2008 11 07 NREMT website Retrieved 2011 09 17 Reciprocity Information NREMT website Retrieved 2011 09 17 Kuehl Alexander 2002 Prehospital systems and medical oversight Dubugue Iowa Kendall Hunt Pub ISBN 978 0 7872 7071 1 Victoria L Fedor Jacob L Hafter 2003 EMS and the Law Sudbury Mass Jones amp Bartlett Publishers ISBN 978 0 7637 2068 1 Kupas Douglas F Schenk Ellen Sholl J Matthew Kamin Richard 2015 04 03 Characteristics of Statewide Protocols for Emergency Medical Services in the United States Prehospital Emergency Care 19 2 292 301 doi 10 3109 10903127 2014 964891 ISSN 1090 3127 PMID 25689221 S2CID 10494952 EMERGENCY MEDICAL SERVICES PRE HOSPITAL STATEWIDE TREATMENT PROTOCOLS Massachusetts Massachusetts Office of Emergency Medical Services 2020 pp appendix A pg 10 Pre Hospital Care Protocols Maine Emergency Medical Services www maine gov Retrieved 2021 03 01 National Association of State EMS Officials National EMS Scope of Practice Model 2019 Report No DOT HS 812 666 Washington DC National Highway Traffic Safety Administration pp 20 National EMS Scope of Practice Model PDF The National Highway Traffic Safety Administration Paramedic Candidate Handbook PDF National Registry of Emergency Medical Technicians 2019 National Registered Paramedics National Registry of Emergency Medical Technicians nremt org Retrieved 2021 02 21 American Academy of Orthopaedic Surgeons 2017 Nancy Caroline s Emergency Care in the Streets 8th ed Burlington MA Jones amp Bartlett Learning pp 501 505 ISBN 978 1 284 14405 5 OCLC 1003284719 National Assoc of Emergency Medical Technicians 2017 AMLS Advanced Medical Life Support 2nd ed Burlington MA Jones amp Bartlett Learning p 7 ISBN 978 1 284 04092 0 OCLC 915774812 Andolsek Christopher M 2013 Intravenous Therapy for Prehospital Providers Mike Kennamer American Academy of Orthopaedic Surgeons 2nd ed Burlington MA Jones amp Bartlett Learning ISBN 978 1 4496 4158 0 OCLC 854239961 American Academy of Orthopaedic Surgeons 2017 Nancy Caroline s Emergency Care in the Streets Nancy L Caroline 8th ed Burlington MA Jones amp Bartlett Learning pp 965 969 1024 1026 ISBN 978 1 284 14405 5 OCLC 1003284719 Friese Greg 2019 How to buy EMS drugs for your department EMS1 Retrieved 2021 02 21 American Academy of Orthopaedic Surgeons 2017 Nancy Caroline s emergency care in the streets Nancy L Caroline 8th ed Burlington MA Jones amp Bartlett Learning p 941 ISBN 978 1 284 14405 5 OCLC 1003284719 Advanced Cardiac Life Support Algorithms cpr heart org 2020 Retrieved 2021 02 21 Adult Tachycardia with a Pulse Algorithm cpr heart org 2020 Retrieved 2021 02 21 Adult Bradycardia with a Pulse Algorithm cpr heart org 2021 Retrieved 2021 02 21 American Academy of Orthopaedic Surgeons 2017 Nancy Caroline s Emergency Care in the Streets Nancy L Caroline 8th ed Burlington MA Jones amp Bartlett Learning p 656 ISBN 978 1 284 14405 5 OCLC 1003284719 Advisories memos and notices for OEMS Mass gov www mass gov Retrieved 2021 02 21 NH Bureau of EMS 2015 Surgical Cricothyrotomy Bougie Assisted Prerequisite Protocol PDF nh gov Calams Sarah 2019 Why point of care ultrasound should be a mainstay in EMS EMS1 Retrieved 2021 02 21 Arizona Department of Health Services 2015 Recommendations for Paramedic Performance of Rapid Sequence Intubation RSI in the Prehospital EMS Environment PDF Emergency Medical Technicians and Paramedics in California PDF Archived from the original PDF on 2006 12 17 Retrieved 2008 11 10 What is a Pediatric Neonatal Critical Care Transport Team PDF Archived from the original PDF on 2008 10 01 Retrieved 2008 11 10 Tactical Paramedic Operations PDF Archived from the original PDF on 2011 07 21 Retrieved 2008 11 10 National Academy of Sciences and National Research Council Accidental Death and Disability The Neglected Disease of Modern Society Washington D C The National Academies Press 1966 Further reading editHazzard Kevin 2022 American Sirens The Incredible Story of the Black Men Who Became America s First Paramedics New York Hachette Books ISBN 9780306926075 OCLC 1291313033 External links editNational Association of Emergency Medical Technicians homepage National Registry of Emergency Medical Technicians NHTSA Emergency Medical Services national page Paramedicine com Retrieved from https en wikipedia org w index php title Paramedics in the United States amp oldid 1186832356, wikipedia, wiki, book, books, library,

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