What are paramedics?
Emergency medical technician-paramedics (EMT-Ps) provide hospital emergency care in the field under medical command authority to acutely ill and/or injured patients and then transport those patients to the hospital by ambulance or other appropriate vehicle. The clinical knowledge possessed by the EMT-P includes the following systems and areas: the cardiovascular system, including the recognition of arrhythmias, myocardial ischemia, and congestive heart failure; the respiratory system, including acute airway obstruction, pneumothorax, chronic obstructive pulmonary disease (COPD), and respiratory distress; trauma to the head, neck, chest, spine, abdomen, pelvis, and extremities; medical emergencies, including acute abdominal infections, diabetes mellitus, and allergic reactions; the central nervous system, including strokes, seizures, and alterations in levels of consciousness; obstetrical emergencies such as eclampsia; pediatric cases, including croup, epiglottitis, dehydration, child abuse, and care of the newborn; psychiatric emergencies, including problems with individuals who are suicidal, assaultive, destructive, resistant, anxious, confused, amnesiac, or paranoid; drug-related problems, including alcoholism, drug addiction, or overdoses; sexual assault and abuse; and various special situations, such as carbon monoxide and other noxious inhalations, poisoning, near drownings, overexposure to heat and cold, electrocution, burns, and exposure to hazardous materials.
The EMT-P must be able to fulfill many roles. First, paramedics must recognize a medical emergency, assess the situation, manage emergency care, and, if needed, extricate the patient. They must also coordinate their efforts with those of other agencies that may be involved in the care and transport of the patient. Paramedics should establish a good rapport with patients and their significant others in order to decrease their state of anxiety.
The next step is to assign priorities to emergency treatment data for the designated medical control authority. Emergency treatment priorities must be assigned in cases where the medical direction is interrupted by communication failure or in cases of immediate, life-threatening conditions. Paramedics must record and communicate pertinent information to the designated medical command authority.
Meanwhile, they must initiate and continue emergency medical care under medical control, including the recognition of presenting conditions and the initiation of appropriate treatments. Such conditions include traumatic and medical emergencies, airway and ventilation problems, cardiac arrhythmias or standstill, and psychological crises. Paramedics must also assess the response of patients to treatment, modifying the medical therapy as directed by the medical control authority. EMT-Ps exercise personal judgment; provide such emergency medical care as has been specifically authorized in advance; direct and coordinate the transport of the patient by selecting the best available methods in concert with the medical command authority; record, in writing, the details related to the patient’s emergency care and the incident; and direct the maintenance and preparation of emergency care equipment and supplies.
EMT-Ps must have a good working knowledge of human anatomy and must be familiar with its topographical language. Even though paramedics are not expected to diagnose every injury or illness, they can aid emergency department personnel by conveying correct information using medical terminology. Such information is gathered after examination of a patient at the scene of an accident or sudden illness.
The most important functions of the paramedic are to identify and treat any life-threatening conditions first and then to assess the patient carefully for other complaints or findings that may require emergency treatment or transportation to a hospital setting. Paramedics must distinguish between signs (measured information such as pulse, respiration, and temperature) and symptoms (patient complaints). They must be able to take complete patient histories, document all medications, and transfer this information to medical control.
The vital role of the respiratory system is stressed in all paramedical training courses. The function of the respiratory system is to provide the body with oxygen and to eliminate carbon dioxide. Paramedics must fully understand the breathing process, including gas exchange and the role and anatomic position of the air passages and lungs. They must understand the mechanics of breathing—how the diaphragm and intercostal muscles contract and relax during inspiration and expiration—and must realize that breathing is controlled by the brain’s response to levels of carbon dioxide and oxygen present in the arterial blood. Of special concern to the paramedic is the patient with COPD, who needs specialized oxygen support and careful watching.
Basic life support (BLS), formerly called cardiopulmonary resuscitation (CPR), is a series of emergency lifesaving procedures that are carried out in order to treat respiratory arrest, cardiac arrest, or both. CPR is a method of providing artificial ventilation and circulation. Its effectiveness depends on the prompt recognition of respiratory and/or cardiac arrest and the immediate start of treatment. Very often, the paramedic is able to defibrillate the patient immediately after cardiac arrest and restart the heart. Knowledge of how to provide BLS to the laryngectomy patient is part of paramedic education; in such cases, ventilation is often given via a stoma (opening) in the neck of the patient. Basic life support procedures must be modified for infants and children, since their respiration and pulse rates are higher than those of adults and require more rapid delivery of ventilatory and cardiac assistance.
Although breathing and heart rate are the primary interests of the paramedic, serious bleeding can also be life-threatening. Hence, paramedics must be well versed in blood circulation routes, control of bleeding, and the pressure points that can help in the control of serious hemorrhage. Serious bleeding often brings on a type of shock that is termed hypovolemic (meaning low blood volume). Paramedics must be alert to signs of impending shock and deal with this condition as soon as possible. Medical antishock trousers (MAST) are often used by paramedics to autotransfuse volumes of blood from the patient’s lower extremities to the heart, lungs, and brain. These trousers are also used to control severe hemorrhage or the complications of pelvic fractures. The paramedic must be aware of the contraindications to the use of these devices as well; for example, persons with head injuries should not have the MAST device applied to them.
Paramedics need to identify the many types of shock. Anaphylactic shock is caused by an unusual or exaggerated allergic reaction of a person to a foreign protein. Psychogenic shock (fainting) is often self-correcting. Septic shock is caused by severe bacterial infections, while metabolic shock may arise from severe, untreated illnesses. Cardiogenic shock arises from an underlying cardiac condition and inefficient blood flow. In each case, the paramedic must be alert to the signs of each type of shock and be prepared to treat it, either with drugs delivered under medical control or with equipment present on the paramedic ambulance.
The more common types of injuries encountered by the paramedic are soft tissue injuries, caused by falls or accidents. The skin is the largest single organ of the body. It protects the body from the environment, regulates the body temperature, and transmits information from the environment to the brain. Soft tissue injuries can cause breaks in the skin, leaving the body vulnerable to infection and bleeding. Paramedic training includes treatment for massive traumatic wounds, such as gunshot or knife wounds.
Dealing with fractures is another part of paramedic training. While most fractures are not life-threatening, they can be painful and bring on patient shock; hence, paramedics need to deal with them quickly. Knowledge of the body’s musculoskeletal system is vital to the performance of a paramedic.
Head injuries are a very challenging part of paramedic treatment, since the scalp contains many blood vessels and bleeding from head injuries is often profuse. The more serious head injury is often bloodless externally, but internal bleeding brings on pressure buildup in the skull and sudden coma. Such injuries are life-threatening and often require rapid treatment and transport.
Other medical emergencies include strokes (cerebrovascular accidents), diabetic coma or insulin shock, acute abdominal infections, and seizures. Prompt recognition and treatment by the paramedic are essential. Finally, treating the pediatric patient can be one of the most difficult emergencies, but saving a child’s life or rescuing a child from permanent, disabling injury is very rewarding. The broad range of knowledge required of paramedics makes them a very special part of the health care team.
Three technologies that distinguish the paramedic from the basic EMT are intravenous therapy, advanced airway management, and defibrillation.
Intravenous (IV) therapy may be an important procedure during the resuscitation of a patient who is suffering from hypovolemia, burn injury, blood loss, heatstroke, shock, electrolyte imbalance, or many other medical and surgical conditions. IV therapy is also important in providing an avenue of medication delivery in many medical situations, such as cardiac arrest, seizures, and asthma attacks. IV therapy is an invasive procedure that requires extensive training in its use in order for the paramedic to maintain the necessary skill level. In addition, paramedics must be aware of the indication for the use of IV therapy, the maintenance of such therapy, and possible complications.
IV therapy works via the infusion of fluid other than blood or blood products into the vascular system. This technique is used to establish and maintain direct access to the circulation or to provide fluids in order to maintain an adequate circulating blood volume. Fluids used for IVs are often referred to as electrolyte solutions, because the chemical compounds they contain are electrolytes. The most common electrolyte solutions used are sodium chloride solutions; for example, NS is a normal saline solution containing 0.9 percent sodium chloride. Occasionally, paramedics use plasma expanders or colloids, including Dextran. A common intravenous fluid is D5W, which is a 5-percent dextrose solution. The procedure for starting an IV includes preparing the solution, selecting the proper catheter size, selecting and preparing the site, and performing the venipuncture (insertion of a needle into a vein). Local complications to IV therapy may include some pain from the needlestick, hematoma formation at failed IV sites, infection, accidental arterial puncture, nerve damage, and thrombophlebitis. Environmental complications include cold climates, which cause IV solutions to freeze, and the danger of a needlestick to medical personnel during disposal. Proper precautions and periodic retraining keep paramedics up to date in their skills.
Advanced airway management means placing a tube into the patient’s airway to maintain an open passage, to prevent aspiration of foreign bodies and stomach contents, and to allow the delivery of oxygen-enriched air. Three types of devices are employed in advanced airway management to achieve these objectives: the endotracheal tube (ENT), the esophageal obturator airway (EOA), and the pharyngeotracheal airway. The use of any of these devices by paramedics requires the consent of a medical director and adherence to written protocols. These devices require skill and instruction for proper insertion and use.
The ENT is placed through a patient’s mouth or nose and directly through the larynx between the vocal cords. The tube may be placed blindly through the vocal cords using sounds of labored respirations as a guide, or it may be placed by feel through the cords. After placement, a soft balloon cuff near the end of the tube is then inflated with approximately 10 cubic centimeters of air to seal the trachea and anchor the tube, so that air can be blown directly into the lungs. The ENT prevents aspiration and gastric distension. It facilitates airway suctioning and enables the delivery of high volumes of oxygen at higher-than-normal pressures. In addition, certain medications may be given down the tube. ENT placement and use are difficult skills to master, requiring considerable practice and expert initial instruction. Direct visualization of the vocal cords is an important skill to have in order to prevent tracheal damage. If intubation takes too long, the resulting delay in oxygenation may lead to brain damage. Constant monitoring of lung sounds is needed to ensure that the tube stays in place.
The EOA has been in use since 1973 to facilitate airway management in cardiopulmonary resuscitation. The EOA is a plastic, semirigid tube approximately 30 centimeters long and 13 millimeters in diameter. The lower end of the tube is smooth, rounded, and closed. The upper third of the EOA is designed to function as an airway. It has sixteen holes in its wall at the junction of the middle and upper sections; when properly inserted, these holes will lie at the level of the pharynx and provide free passage of oxygen-enriched air to the lungs. The lower two-thirds of the EOA should lie in the esophagus. The balloon surrounding the end of the tube is normally inflated to block the esophagus and prevent the regurgitation of stomach contents backward into the airway. The face mask that comes with the EOA is designed to fit snugly about the patient’s nose and mouth and must provide a tight seal. The EOA is used only for short-term airway management. It should be removed when the unconscious patient awakens and is able to protect the airway or when ENT placement has been performed over the EOA. At the time that the balloon is deflated and the EOA is removed, there is a high risk of vomiting and/or regurgitation of gastric contents. The EOA is not to be used on patients who are awake, on small children, or on patients with known esophageal disease.
The pharyngeotracheal airway is designed to provide lung ventilation when placed in either the trachea or the esophagus. This device is designed to be inserted blindly into the oropharynx and esophagus by paramedics who have received training and are authorized to use it. A pharyngeotracheal airway is contraindicated in conscious or semiconscious patients with a gag reflex. It should not be used with children under the age of fourteen or with adults under five feet tall.
With the use of any of these airway devices, the patient may regain consciousness while intubated. Such patients will usually gag, choke, and grasp at the device in an attempt to remove it, often resulting in injury to the airway. The patient’s hands must be immediately restrained while the airway device is removed.
Defibrillation is the delivery of an electric current through a person’s chest wall and heart for the purpose of ending ventricular fibrillation. The device used for this procedure is called a defibrillator (also automated external defibrillator or AED); it is typically a portable, battery-powered instrument that is used to record cardiac rhythm and to generate and deliver an electrical charge. Defibrillation can be a lifesaving measure in the treatment of sudden cardiac arrest in which the heart is in an arrhythmia known as ventricular fibrillation or ventricular tachycardia (VT). These two conditions occur when cardiac muscle becomes oxygen deficient or is injured or dies, causing the electrical system of the heart to be disturbed. Sometimes, the injured area of the heart begins to fire off uncoordinated electrical impulses. These irregular impulses can initiate abnormal beats called premature ventricular contractions (PVCs). If several of the PVCs occur close together, they produce the rhythm called ventricular tachycardia. If VT does not spontaneously convert back to a normal heart rhythm, it rapidly degenerates into ventricular fibrillation. The heart in VT beats faster and faster until its oxygen supply is depleted, at which point tissue injury begins and electrical impulses become completely uncoordinated and are fired at random.
If a defibrillator is applied to the patient and an electrical shock is given to the heart during the time of ventricular fibrillation, there is a good chance of restoring more normal electrical activity. This electrical countershock is thought to depolarize the cardiac muscle and conducting tissues instantaneously, thus resetting the electrical energies to the depolarized state. The patient’s heart can then begin its normal conduction and contractions without having to contend with randomly generated electrical impulses. The electrical current delivered by defibrillators is measured in units called joules. In most protocols, the first shock is 200 joules, the second is between 200 and 300 joules, and the third and subsequent shocks are at the full 360-joule level. Paramedics using defibrillators need frequent continuing education in order to emphasize the practical skills of proper attachment of the electrodes, proper device operation, and recognition of cardiac arrhythmias.
Emergency medical services (EMS) in the United States had its beginnings in 1966. In that year, the Committees on Trauma and Shock of the National Academy of Sciences National Research Council jointly published Accidental Death and Disability: The Neglected Disease of Modern Society. This joint report brought public attention to the inadequate emergency medical care being provided to the injured and sick in many parts of the United States. Two federal agencies initiated reform measures: The Department of Transportation (DOT) initiated the Highway Safety Act in 1966, and the Department of Health, Education, and Welfare enacted the Emergency Medical Services Act in 1973. Both created funding sources to develop prehospital emergency care in an effort to eliminate the majority of prehospital deaths. Local EMS systems were established in the early 1970s. In the 1980s, practitioners took a hard look at what had been done in the past, and the focus changed from establishing EMS systems to developing educational programs to provide consistent levels of quality care to the sick and injured.
The EMS system is made up of various components that work together to provide the sick and injured with the best possible emergency care in the shortest possible time. The EMS system represents the combined efforts of the first responder, the EMT with basic life support skills, the EMT-paramedic with advanced life support skills, emergency department personnel, physicians, allied health personnel, hospital administrators, EMS system administrators, and the overseeing governmental agencies.
Emergency medical technology is an exciting field of study. Few areas offer more direct application of theory and skills. All the information received in an EMT class will be important when it comes to saving lives and lessening human suffering. Emergency medical technology combines theoretical information, practical skills, and common sense. Above all, the EMS person dealing with a patient must possess great compassion and understanding.
The certification of an EMT-paramedic is formal notice of certain privileges and abilities after the completion of specific training and testing. The possession of a certificate obligates the individual to conform to the standard of care of other certified emergency medical care personnel. Nearly every state exempts emergency medical care from the licensure requirements of the Medical Practices Act for nonmedical personnel. (Because many emergency medical care procedures may be construed by the public to be the performance of a medical act, the EMT must be protected legally in those situations.) The need for prehospital care providers is ongoing, and recruiting people to enter this field continues to be a challenge to the agencies that oversee this work.
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