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134-616: The mission of the California EMS Authority is to ensure quality patient care by administering an effective, statewide system of coordinated emergency medical care, injury prevention, and disaster medical response. In California, the EMS Authority is responsible for paramedic licensure, emergency medical technician regulations, trauma center and trauma system standards, ambulance service coordination, and disaster medical response. The EMS Authority operates

268-647: A physician medical director , often with the advice of a medical advisory committee composed of paramedics and other health professionals. In California, for example, each county's local emergency medical service agency (LEMSA) issues a list of standard operating procedures or protocols, under the supervision of the California Emergency Medical Services Authority . These procedures often vary from county to county based on local needs, levels of training and clinical experiences. New York State has similar procedures, whereas

402-478: A PCP and ACP may run 40–50 medical codes per year, a CCP may run 1–2 in an entire career. IV/IO starts are nearly non-existent in the field and for this reason CCPs are required to attend nearly double the amount of time in classroom situations or in hospital to keep current. In addition to this, they are trained for other skills such as medication infusion pumps, mechanical ventilation, and arterial line monitoring. CCPs often work in fixed and rotary wing aircraft when

536-625: 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

670-434: A benchmarking document to permit inter-provincial labour mobility of practitioners, regardless of how titles are specifically regulated within their own provincial systems. In this manner, the confusing myriad of titles and occupational descriptions can at least be discussed using a common language for comparison sake. Most providers that work in ambulances are identified as "paramedics" by the public. However, in many cases,

804-465: A clinical lead working alongside an emergency care assistant or as assistants themselves to a paramedic. As the role does not have a single defined scope, the skills they have can include: The term emergency medical technician is not commonly used by members of the public in the United Kingdom. Instead, it is common for all ambulance personnel to be referred to as "paramedics", although

938-549: A common hazard faced by paramedics, where safety goggles can be used for eye protection. Underhand protection, paramedics can employ gloves mainly to curb burns. One of the principles of PPE is that choices should be guided by specific risks associated with various emergencies, which warrant different PPE requirements. Paramedic are involved in challenging professions and can be subject to different kinds of psychological stress , for instance, post-traumatic stress disorder , depression , or severe burnout . The psychological aspect

1072-483: A disaster. Disaster Healthcare Volunteers is California's initiative to pre-register, verify licensure and credentials, and mobilize professional healthcare volunteers. The program has roughly 14,000 registrants representing 47 professional license types including doctors, dentists, nurses, paramedics, pharmacists, technicians, etc. Paramedic programs were established as a county option in California in 1971 by

1206-1035: A few additional medications. Advanced care paramedic (ACP) is a level of practitioner that is in high demand by many services across Canada. However, Quebec only utilizes this level of practice in a very limited fashion as part of a pilot program in Montreal. The ACP typically carries approximately 20 different medications, although the number and type of medications may vary substantially from region to region. ACPs perform advanced airway management including intubation, surgical airways, intravenous therapy, place external jugular IV lines, perform needle thoracotomy, perform and interpret 12-lead ECGs, perform synchronized and chemical cardioversion, transcutaneous pacing, perform obstetrical assessments, and provide pharmacological pain relief for various conditions. Several sites in Canada have adopted pre-hospital fibrinolytics and rapid sequence induction, and prehospital medical research has permitted

1340-467: A five-year period, and 93% stop treating within 10 years. 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

1474-502: A given level of paramedic practice, each province retains ultimate authority in legislating the actual administration and delivery of emergency medical services within its own borders. For this reason, any discussion of paramedic practice in Canada is necessarily broad, and general. Specific regulatory frameworks and questions related to paramedic practices can only definitively be answered by consulting relevant provincial legislation, although provincial paramedic associations may often offer

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1608-455: A great number of variations in the scope of practice for ACPs. Current programs include providing ACPs with discretionary direct 24-hour access to PCI labs, bypassing the emergency department, and representing a fundamental change in both the way that patients with S-T segment elevation myocardial infarctions (STEMI) are treated, but also profoundly affecting survival rates, as well as bypassing closer hospitals to get an identified stroke patient to

1742-479: 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, 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

1876-445: A handful of universities also offer a four-year bachelor's degree component. 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. Calendar length typically varies from 12 months to upwards of two years, excluding degree options, EMT training, work experience, and prerequisites. It

2010-551: 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

2144-399: A limited set of medications (including oxygen, epinephrine, dextrose, naloxone, albuterol, ipratropium bromide , glucagon, nitroglycerin, nitrous oxide , and acetylsalicylic acid). Some areas may add to the scope of practice, including intravenous access, insertion of supraglottic airway devices, and CPAP . Training requirements and treatment protocols vary from area to area. Advanced EMT

2278-549: A major concern in light of the COVID-19 pandemic . In response, the U.S. Centers for Disease Control and Prevention and other agencies and organizations have issued guidance regarding workplace hazard controls for COVID-19 . Some specific recommendations include modified call queries, symptom screening, universal PPE use, hand hygiene, physical distancing, and stringent disinfection protocols. Research on ambulance ventilation systems found that aerosols often recirculate throughout

2412-486: 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

2546-560: A paramedic varies widely across the world, as EMS providers operate with many different models of care . In the Anglo-American model, paramedics are autonomous decision-makers. In some countries such as the United Kingdom and South Africa, the paramedic role has developed into an autonomous health profession. In the Franco-German model, ambulance care is led by physicians. In some versions of this model, such as France, there

2680-560: 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. Prior to World War I motorized ambulances started to be developed, but once they proved their effectiveness on

2814-610: A rapid response vehicle / helicopter. The role of paramedics in Germany has evolved from support to physicians in the field to the central role in pre-hospital emergency care. The development of the profession has been a gradual move from simply transporting patients to hospital, to more advanced treatments in the field. In some countries, the paramedic may take on the role as part of a system to prevent hospitalization entirely and, through practitioners, are able to prescribe certain medications , or undertaking 'see and refer' visits, where

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2948-600: A regional medical-advisory council (REMAC) determines protocols for one or more counties in a geographical section of the state. Treatments and procedures administered by paramedics fall under one of two categories, off-line medical orders (standing orders) and on-line medical orders. On-line medical orders refers to procedures that must be explicitly approved by a base hospital physician or registered nurse through voice communication (generally by phone or radio) and are generally rare or high risk procedures (e.g. vasopressor initiation). In addition, when multiple levels can perform

3082-460: 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. As a part of Emergency Medicine Reform in 2017 Ministry of Healthcare introduced two specialties — "paramedic" and " emergency medical technician ". Paramedics are employed by

3216-429: 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

3350-416: A sense to medical school clinical rotations, EMT students are required to spend a required amount of time in an ambulance and on a variety of hospital services (e.g. obstetrics , emergency medicine , surgery , intensive care unit , psychiatry ) in order to complete a course and become eligible for the certification and licensure exams. The number of clinical hours for both time in an ambulance and time in

3484-568: A set of protocols, which are typically written by a physician . EMTs are exposed to a variety of hazards such as lifting patients and equipment, treating those with infectious disease, handling hazardous substances, and transportation via ground or air vehicles. Employers can prevent occupational illness or injury by providing safe patient handling equipment, implementing a training program to educate EMTs on job hazards, and supplying PPE such as respirators, gloves, and isolation gowns when dealing with biological hazards. Infectious disease has become

3618-731: A set of skills practised by paramedics in the pre-hospital setting commonly includes: 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: 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

3752-415: 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 ". 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

3886-574: A simpler overview of this topic when it is restricted to a province-by-province basis. In Canada, the levels of paramedic practice as defined by the National Occupational Competency Profile are: emergency medical responder (EMR), primary care paramedic, advanced care paramedic, and critical care paramedic. Regulatory frameworks vary from province to province, and include direct government regulation (such as Ontario's method of credentialing its practitioners with

4020-838: A state lead agency and centralized resource to deal with emergency and disaster medical services. Previous Directors of the California Emergency Medical Services Authority were: Roger Taylor MD (1981-1982), George Moorhead (Acting, 1982–1983), Kenneth Kizer MD (1983-1984), George Moorhead (Acting, 1984–1986), Bruce Haynes MD (1986-1989), Daniel Smiley (Acting, 1989–1993), Joseph Morales MD (1993-1997), Richard Watson (Acting, 1997–2005), Cesar Aristeiguieta MD (2005-2007), Daniel Smiley (Acting 2007–2008), R. Steven Tharratt MD (2008-2010), Daniel Smiley (Acting 2010–2011), Howard Backer MD (2011-2019), Julie Souliere (Acting 2019), Dave Duncan MD (2019-2021), Elizabeth Basnett (2021–present. Daniel Smiley served as

4154-476: A stroke centre. Critical care paramedics (CCPs) are paramedics who generally do not respond to 9-1-1 emergency calls, with the exception of helicopter "scene" calls. Instead they focus on transferring patients from the hospital they are currently in to other hospitals that can provide a higher level of care. CCPs often work in collaboration with registered nurses and respiratory therapists during hospital transfers. This ensures continuity of care. However, when acuity

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4288-690: A training program to educate paramedics on job hazards, and supplying PPE such as respirators, gloves, and isolation gowns when dealing with biological hazards. Infectious disease has become a major concern, in light of the COVID-19 pandemic . In response, the U.S. Centers for Disease Control and Prevention and other agencies and organizations have issued guidance regarding workplace hazard controls for COVID-19 . Some specific recommendations include modified call queries, symptom screening, universal PPE use, hand hygiene, physical distancing, and stringent disinfection protocols. Research on ambulance ventilation systems found that aerosols often recirculate throughout

4422-647: A transporting ambulance. EMT training programs for certification vary greatly from course to course, provided that each course at least meets local and national requirements. In the United States, EMRs receive at least 40–80 hours of classroom training and EMTs receive at least 120–300 hours of classroom training. AEMTs generally have 100-300 hours of additional classroom training beyond the standard EMT training. Paramedics are trained for 1,500–2,500 hours or more. In addition to each level's didactic education, clinical rotations are typically also required. Similar in

4556-410: A variety of different organizations, and the services they provide may occur under differing organizational structures, depending on the part of the world. A new and evolving role for paramedics involves the expansion of their practice into the provision of relatively basic primary health care and assessment services. Some paramedics have begun to specialize their practice, frequently in association with

4690-441: A variety of medical procedures such as endotracheal intubation, rapid sequence induction , cricothyrotomy , fluid resuscitation , drug administration, obtaining intravenous and intraosseous access, manual defibrillation, electrocardiogram interpretation, capnography, cardioversion , transcutaneous pacing , pericardiocentesis , thoracostomy , ultrasonography , and blood chemistry interpretation. An ambulance with only EMTs

4824-492: Is a healthcare professional trained in the medical model, whose main role has historically been to respond to emergency calls for medical help outside of a hospital. Paramedics work as part of the emergency medical services (EMS), most often in ambulances . They also have roles in emergency medicine, primary care, transfer medicine and remote/offshore medicine. The scope of practice of a paramedic varies between countries, but generally includes autonomous decision making around

4958-512: Is a level of practice that is least comprehensive (clinically speaking), and is also generally not consistent with any medical acts beyond advanced first-aid and oxygen therapy, administration of ASA, I.M. epinephrine and glucagon, oral glucose and administration of intranasal Narcan with the exception of automated external defibrillation (which is still considered a regulated medical act in most provinces in Canada). Primary care paramedics (PCP) are

5092-697: Is a medical professional that provides emergency medical services . EMTs are most commonly found serving on ambulances and in fire departments in the US and Canada, as full-time and some part-time departments require their firefighters to at least be EMT certified. In English-speaking countries, paramedics are a separate profession that has additional educational requirements, qualifications, and scope of practice. EMTs are often employed by public ambulance services, municipal EMS agencies, governments , hospitals , and fire departments . Some EMTs are paid employees, while others (particularly those in rural areas ) are volunteers . EMTs provide medical care under

5226-505: Is a nonprofit organization which offers certification exams based on NHTSA education guidelines and has been around since the 1970s. Currently, NREMT exams are used by 46 states as the sole basis for certification at one or more EMT certification levels. A NREMT exam consists of skills and patient assessments as well as a written portion. On June 12, 2019, the NREMT changed the rules regarding age limits for EMTs, AEMTs, and paramedics. There

5360-434: Is an emergency or routine operation. Such regulatory bodies, as the ones promoting national and global safety standards, ensure that evidence-based approaches reinforce adherence to their occupational health being safeguarded. Throughout the evolution of pre-hospitalization 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

5494-421: Is an extra risk for CVDs because of the heaviness of emergency response operations. There is a need to emphasize cancer risk and the importance of constant exploration and individualized prevention patterns. Besides, there is the cumulative effect of fatigue, violence, and trauma on the health of paramedics. As a result, there is a need for systematic monitoring and preventive measures in health among paramedics. It

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5628-422: Is closely related to other healthcare positions, especially the emergency medical technician , with paramedics often being at a higher grade with more responsibility and autonomy following substantially greater education and training. The primary role of a paramedic is to stabilize people with life-threatening injuries and transport these patients to a higher level of care (typically an emergency department). Due to

5762-620: Is common for Paramedics to continue to progress through "top up" courses, for instance, to work towards a Bachelors of Science degree. This has led to Paramedics holding a wide range of qualifications, with some qualifications (such as master's degrees in Advanced or Paramedic Practice) being a pre-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 ,

5896-416: Is considered a basic life support (BLS) unit, an ambulance utilizing AEMTs is dubbed an "intermediate life support" (ILS), or "limited advanced life support" (LALS) unit, and an ambulance with paramedics is dubbed an " advanced life support " (ALS) unit. Many states allow ambulance crews to contain a mix of crews levels (e.g. an EMT and a paramedic or an AEMT and a paramedic) to staff ambulances and operate at

6030-991: Is critical. Including, the immediate disposal of sharps in puncture-resistant containers and wearing appropriate personal protective equipment (PPE) and strict adherence to post-exposure protocols, enhances safety. Additionally, staying updated with vaccinations , including those for flu , COVID-19 , Hepatitis B . Furthermore, adhering to infection control practices, such as hand hygiene , environmental cleaning, and specialized control programs, are vital for preventing infections like MRSA , TB , and COVID-19 . Personal Protective Equipment (PPE) usage in implementation and vaccination compliance are effective transmission reduction measures for infectious diseases among paramedics. Exposures to blood pathogens and body fluids through incidents, for example, needlestick injuries which jeopardizes paramedics at risk of infectious diseases such as Hepatitis B , and Hepatitis C , and HIV affecting around 6,000 EMS workers. This realization strengthens

6164-420: Is intertwined with the nature of the paramedics' work. Exposure to traumatic events such as accidents, medical emergencies , and violence are some of the factors undermining the psychological health of paramedics. Mental health issues, including depression , anxiety , and substance abuse , are some of the mental health issues paramedics are likely to get exposed to due to their nature of work as compared to

6298-537: Is manageable by a CCP or a registered nurse or respiratory therapist is not available, CCPs will work alone. Providing this care to the patient allows the sending hospital to avoid losing highly trained staff on hospital transfers. CCPs are able to provide all of the care that PCPs and ACPs provide. That being said, CCPs significantly lack practical experience with advanced skills such as IV initiation, peripheral access to cardiovascular system for fluid and drug administration, advanced airway, and many other techniques. While

6432-666: Is necessary to study long-term health risks for paramedics and apply a prophylactic approach to maintaining the health state of healthcare professionals. The regulatory guidelines are fundamental in eliminating occupational risk in paramedicine ; authoritative bodies like the Occupational Safety and Health Administration (OSHA) and the World Health Organization (WHO) provide specific guidelines. For example, in United States, physical , chemical , and biological hazards are managed by operating under

6566-480: Is no direct equivalent to a paramedic. Ambulance staff have either the more advanced qualifications of a physician or less advanced training in first aid . In other versions of the Franco-German model, such as Germany, paramedics do exist. Their role is very similar to the role of paramedics in the Anglo-American model with an advanced scope of autonomy and practice, and the added element of emergency physician backup, either virtually ( Tele-Notarzt ) or on scene with

6700-413: Is no longer an age limit for registered personnel. However, applicants must successfully complete a state-approved EMT course that meets or exceeds the NREMT standards within the past two years of applying. Those applying for the NREMT certification must also complete a state-approved EMT psychomotor exam. It is possible for the candidate to be refused access to a state-approved course due to their age within

6834-683: Is required to be a certified Emergency Medical Technician prior to starting paramedic training. 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

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6968-431: Is the level of training between EMT and paramedic. They can provide intermediate life support (ILS) care including obtaining intravenous or intraosseous access, basic cardiac monitoring, fluid resuscitation , capnography, and administration of some additional medications. Paramedics typically represent the highest degree of pre-hospital medical provider, providing advanced life support (ALS) care. Paramedics perform

7102-725: The COVID-19 crisis. EMTs are a vital part of the private, voluntary and auxiliary services where a practitioner must be on board any ambulance in the process of transporting a patient to hospital. This is mandatory for all PHECC registered practitioners to keep their practitioner level and should always be kept in date (two years). This course is the new standard for first aid in the workplace. Basic tactical emergency care A state-level exam needs to be completed before an invitation to register as an EMT. EMT's are trained in basic life support, anatomy - physiology , pathophysiology , pharmacology , ECG monitoring, advanced airway management (supraglottic airways), spinal immobilization and

7236-787: 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

7370-609: 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. 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

7504-549: 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

7638-467: 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

7772-623: 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

7906-516: The Philippines based on the standard set down by the Department of Health . Técnico en Emergencias Sanitarias (TES) are trained a total of 2000hrs in 2 years with 3 months of internship in ambulances at the very end. It's the only level of EMS worker. BLS ambulances can be driven with a B license, ALS with a C1. Emergency medical technician is a term that has existed for many years in

8040-496: The Pre-Hospital Emergency Care Council (PHECC). Emergency medical technician is the entry-level standard of practitioner for employment within the ambulance service . Currently, EMTs are authorized to work on non-emergency ambulances only as the standard for emergency ( 999 ) calls is a minimum of a two-paramedic crew, although this minimum requirement was relaxed to and EMT - paramedic crew during

8174-453: 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

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8308-525: The military . The majority of paramedics are employed by the emergency medical service for their area, although this employer could itself be working under a number of models, including a specific autonomous public ambulance service, a fire department, a hospital based service, or a private company working under contract. In Washington , firefighters have been offered free paramedic training. There are also many paramedics who volunteer for backcountry or wilderness rescue teams, and small town rescue squads. In

8442-483: The Chief Deputy Director, and periodic acting Director, for 31 years from 1989 until 2019. The EMS Authority is charged with providing leadership in developing and implementing Emergency Medical Services (EMS) systems throughout California. In California, day-to-day EMS system management is a local responsibility. Each county developing an EMS system must designate a local EMS agency (LEMSA) which can be

8576-531: The EMS Central Registry , a public access database that provides information about licensing and certification status of EMTs and paramedics. The EMS Authority manages the state's medical response to major disasters. This includes maintenance, staffing and deployment of three 200-bed mobile field hospitals, 39 Disaster Medical Support Units that supply ambulance strike teams, and three 40-person medical assistance teams that are prepared to respond to

8710-585: The FAQ Level 4 Diploma for Associate Ambulance Practitioners & QA Level 5 Diploma in First Response Emergency and Urgent Care (RQF) This provided a defined scope of practice agreed nationally by ambulance service trusts . Their role title, however, may still be defined by their employer as emergency medical technician . They can work autonomously, making their own clinical decisions within their training and remit. They may also work as

8844-649: The NREMT posted information about a transition to a new system of levels for emergency care providers developed by NHTSA with the National EMS Scope of Practice Project. By 2014, these new levels replaced the fragmented system found around the United States. The new classification includes emergency medical responder (replacing first responder), emergency medical technician (replacing EMT-basic), advanced emergency medical technician (replacing EMT-intermediate/85), and paramedic (replacing EMT-intermediate/99 and EMT-paramedic). Education requirements in transitioning to

8978-474: The United Kingdom, but has no single defined scope. They may be known as emergency medical technician or simply, ambulance technician . Most EMTs hold an Institute for Healthcare Development Ambulance Technician Certificate and are employed in private ambulance companies or in National Health Service ambulance trusts. As of 2016, The IHCD Ambulance Technician Certificate was replaced with

9112-470: The United States has an EMS lead agency or state office of emergency medical services that regulates and accredits EMT training programs. Most of these offices have web sites to provide information to the public and individuals who are interested in becoming an EMT. In the United States, an EMT's actions in the field are governed by state regulations, local regulations, and by the policies of their EMS organization. The development of these policies are guided by

9246-660: 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 Department 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

9380-504: The Wedworth-Townsend Pilot Paramedic Act (SB 772). Los Angeles County became the first county in California with paramedics. The popular television show Emergency! demonstrated the potential for improved pre-hospital care. Paramedic programs began to be established in many counties in California. Before 1980, the responsibility for emergency medical services (EMS) and disaster medical preparedness

9514-943: The administration of medication typically oral , intramuscular , inhaled, nebulised or sublingual . Whilst paramedics in Ireland do work on front-line ambulances the PHECC standards for are generally lower than most of the world leaders in pre-hospital care. Paramedics are trained to the EMT standard and additional training in advanced pharmacology, anatomy, advanced airway management (supraglottic airways), some advanced life support skills, 12-leads ECGs, administration of medication typically oral, intramuscular, inhaled, nebulised or sublingual, and they are also allowed to maintain IV lines. Emergency medical technician (EMT), paramedic (P) and advanced paramedic (AP) are legally defined and protected titles in

9648-540: 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 , emergency medical technicians , and paramedics. Today, university qualifications are expected for paramedics, with the current entry level being a Bachelor of Science degree in Pre-Hospital Care or Paramedic Science. As

9782-458: The back and neck, and injuries are most prevalent while responding to 911 calls, which include patient care and transport. These injuries are prevalent but not impossible to overcome; they require preventive measures to minimize the chance of them happening. Safe lifting techniques and patient-handling equipment are major factors in reducing paramedics’ physical injury risk. Workers with less than 10 years’ experience are most at risk, pointing to

9916-510: 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. Emergency Medical Technician - United States (120-200 hrs. education) Emergency Medical Responder - Canada (80 hrs. education) Emergency medical technician An emergency medical technician (often, more simply, EMT )

10050-469: 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

10184-404: The battlefield to their own communities, and commenced the creation of volunteer life-saving squads and ambulance corps. 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

10318-437: 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

10452-597: The compartment, creating a health hazard for EMTs when transporting sick patients capable of airborne transmission. Unidirectional airflow design can better protect workers. There is considerable degree of inter-provincial variation in the Canadian paramedic practice. Although a national consensus (by way of the National Occupational Competency Profile) identifies certain knowledge, skills, and abilities as being most synonymous with

10586-418: The compartment, creating a health hazard for paramedics when transporting sick patients capable of airborne transmission. Unidirectional airflow design can better protect workers. To further safeguard paramedics, incorporating evidence-based strategies for managing chemical exposures and environmental risks is crucial. Agencies such as OSHA , WHO and NIOSH offer comprehensive guidelines that highlight

10720-398: The county health department, an agency established and operated by the county, an entity with which the county contracts for the purposes of EMS administration or a joint powers agency. There are 34 single-county or multi-county local EMS agencies. It is principally through these agencies that the EMS Authority works to promote quality EMS services statewide. Paramedic A paramedic

10854-778: The crew with patient care and packaging. EMRs provide advanced first aid-level care, CPR, semi-automatic defibrillation, basic airway management (suction/oropharyngeal airway), oxygen therapy, and administration of basic, life-saving medications such as epinephrine and naloxone. EMT is the next level of EMS certification and is considered the most common entry level of training. The procedures and skills allowed at this level include bleeding control, management of burns, splinting of suspected fractures and spinal injuries, childbirth, cardiopulmonary resuscitation, semi-automatic defibrillation, oral suctioning, insertion of oropharyngeal and nasopharyngeal airways, pulse oximetry , blood glucose monitoring, auscultation of lung sounds, and administration of

10988-430: 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

11122-425: The emergency care of patients. Not all ambulance personnel are paramedics, although the term is sometimes used informally to refer to any ambulance personnel. In some English-speaking countries, there is an official distinction between paramedics and emergency medical technicians (or emergency care assistants ), in which paramedics have additional educational requirements and scope of practice. The paramedic role

11256-602: The entry-level of paramedic practice in Canadian provinces. The scope of practice includes performing semi-automated external defibrillation , interpretation of 4-lead ECGs, administration of symptom relief medications for a variety of emergency medical conditions (these include oxygen, epinephrine, dextrose , glucagon, salbutamol , ASA and nitroglycerine ), performing trauma immobilization (including cervical immobilization ), and other fundamental basic medical care. Primary care paramedics may also receive additional training in order to perform certain skills that are normally in

11390-640: The environment in which they will work. Some early examples of this involved aviation medicine and the use of helicopters , and the transfer of critical care patients between facilities. While some jurisdictions still use physicians, nurses, and technicians for transporting patients, increasingly this role falls to specialized senior and experienced paramedics. Other areas of specialization include such roles as tactical paramedics working in police units, marine paramedics, hazardous materials ( Hazmat ) teams, Heavy Urban Search and Rescue , and paramedics on offshore oil platforms , oil and mineral exploration teams, and in

11524-534: 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. This

11658-677: 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

11792-514: The form of environmental and operational risks , primarily during transportation. These transportation-related hazards should be considered and addressed in prehospital care . Slips, trips, and falls; motor vehicle incidents ; and violence or assaults have huge impact on paramedics' occupational hazards , resulting to thousands of paramedics impacted annually. Vehicle safety features need to be known by paramedics, and so must undergo exhaustive emergency driving training, which looks into curbing

11926-472: 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

12060-407: The general population. Stable support systems that may include peer counselling and the availability of mental health resources become essential in building the resilience of paramedic professionals. Peer counselling programs appear to be an effective stress management strategy for paramedics. Taking part in open discussions with other peers who understand what the employee is going through determines

12194-452: The guidelines and recommendations offered by NIOSH and OSHA , targeting the healthcare industry especially. These include properly using PPE , handling hazardous substances, and adequately managing workplace violence . Moreover, the WHO provides global views by laying international standards to protect the well-being of the staff involved in the healthcare provided, irrespective of whether it

12328-483: The hospital vary depending on local requirements, the level the student is obtaining, and the amount of time it takes the student to show competency. In addition, a minimum of continuing education (CE) hours is required to maintain certification. For example, to maintain NREMT certification, EMTs must obtain at least 48 hours of additional education and either complete a 24-hour refresher course or complete an additional 24 hours of CE that cover, on an hour by hour basis,

12462-532: The integration of safety protocols, technological advancements, and procedural innovations to enhance paramedic safety and well-being. Paramedics are widely recognized to face high risks of physical injuries in their line of work. More than 22,000 EMS providers visit the emergency room each year for work-related injuries. Some physical injuries encountered when providing healthcare services include lifting injuries, back strains , and needlestick incidences. Injuries such as sprains and strains mostly occur in

12596-459: 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)

12730-412: 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

12864-537: The length of training may be eight months in British Columbia or two to four years in Ontario, Alberta, and Quebec. The nature of training and how it is regulated, like actual paramedic practice, varies from province to province. Emergency medical technician (EMT), paramedic (P) and advanced paramedic (AP) are legally defined and protected titles in the Republic of Ireland based on the standard set down by

12998-625: 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

13132-459: The level of the highest trained provider. There is nothing stopping supplemental crew members to be of a certain certification, though (e.g. if an ALS ambulance is required to have two paramedics, then it is acceptable to have two paramedics and an EMT). An emergency vehicle with only EMRs or a combination of both EMRs and EMTs is still dubbed a "basic life support" (BLS) unit. An EMR must usually be overseen by an EMT-level provider or higher to work on

13266-401: 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

13400-401: The most prevalent level of emergency pre-hospital care is that which is provided by an emergency medical responder (EMR). This is a level of practice recognized under the National Occupational Competency Profile, although unlike the next three successive levels of practice, the high number of EMRs across Canada cannot be ignored as contributing a critical role in the chain of survival, although it

13534-542: The nature of their job, paramedics work in many environments, including roadways, people's homes, and depending on their qualifications, wilderness environments, hospitals, aircraft, and with SWAT teams during police operations. Paramedics also work in non-emergency situations, such as transporting chronically ill patients to and from treatment centers and in some areas, address social determinants of health and provide in-home care to ill patients at risk of hospitalization (a practice known as community paramedicine ). The role of

13668-476: The necessary supportive grounds that facilitate managing and processing feelings related to this work. The long-term health risks that need to be observed by the paramedics are Post Traumatic Stress Disorder (PTSD) , cardiovascular diseases (CVDs) , and cancer risk. There are a variety of challenges paramedics encounter, including PTSD , which should provide a compelling reason to implement preventive mental health measures within this profession. Moreover, there

13802-428: The need for science-based methods in preventing the occupational risks posed by infectious diseases with a foregrounding of the role of preventative measures geared towards protecting the health of paramedic professionals and, at the same time, the community. Paramedics encounter daily risks associated with handling hazardous chemicals . As a result, they must understand how to deliver care safely to remain protected in

13936-529: The need for targeted prevention strategies for newer employees. By employing the proposed measures to reduce physical injuries, it will be possible to mitigate the hazards faced by paramedics, to help paramedics stay safe while rendering the most needed services. The risk of contracting infectious diseases is common in the paramedic profession. The COVID-19 pandemic strengthens the necessity of following safety protocols. Preventive measures for healthcare workers from needlestick injuries and infectious disease

14070-447: The new levels are substantially similar. EMR is the most basic level of training, and is considered the bare minimum certification for rescuers that respond to medical emergencies. EMRs are typically on-call volunteers in rural communities, or are primarily employed as firefighters or search and rescue personnel. EMRs typically arrive quickly and assess and stabilize the patient before the transporting ambulance arrives, and then assist

14204-458: The options in the standing orders had been exhausted. 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,

14338-415: The paramedic directly refers a patient to specialist services without taking them to hospital. Paramedics are exposed to a variety of hazards such as lifting patients and equipment, treating those with infectious disease, handling hazardous substances, and transportation via ground or air vehicles. Employers can prevent occupational illness or injury by providing safe patient handling equipment, implementing

14472-598: The paramedic title is protected under registration of the Health and Care Professions Council . In the United States, EMTs are certified according to their level of training. Individual states set their own standards of certification (or licensure, in some cases) and all EMT training must meet the minimum requirements as set by the National Highway Traffic Safety Administration 's (NHTSA's) standards for curriculum. The National Registry of Emergency Medical Technicians (NREMT)

14606-545: 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

14740-487: 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. Changes in procedures also included the manner in which the work of paramedics was overseen and managed. In

14874-564: The provisions that are the peril of transportation. Paramedics are frequently assaulted by patients or bystanders affecting around 2,000 EMS workers annually, which further hammers the need for training on de-escalation. NIOSH and the Department of Homeland Security have conducted ambulance crash testing, resulting in the development of 10 test methods published by the Society of Automotive Engineers (SAE) to reduce and eliminate crash-related injuries to EMS workers. Through effective training,

15008-549: The same country or state. For instance, in Canada, the province of British Columbia operates a province-wide service (the British Columbia Ambulance Service ) whereas in Ontario , the service is provided by each municipality, either as a distinct service, linked to the fire service , or contracted out to a third party. While there are varying degrees of training and expectations around the world,

15142-483: The same procedure (e.g. AEMT-critical care and paramedics in New York), a procedure can be both an on-line and a standing order depending on the level of the provider. Since no set of protocols can cover every patient situation, many systems work with protocols as guidelines. Systems also have policies in place to handle medical direction when communication failures happen or in disaster situations. The NHTSA curriculum

15276-529: 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

15410-612: The same topics as the refresher course would. Recertification for other levels follows a similar pattern. EMT training programs vary greatly in calendar length (number of days or months). For example, fast track programs are available for EMTs that are completed in two weeks by holding class for 8 to 12 hours a day for at least two weeks. Other training programs are months long, or up to two years for paramedics in associate degree programs. EMT training programs take place at numerous locations, such as universities, community colleges, technical schools, hospitals or EMS academies. Every state in

15544-544: The scope of practice of advanced care paramedics. This is regulated both provincially (by statute) and locally (by the medical director), and ordinarily entails an aspect of medical oversight by a specific body or group of physicians. This is often referred to as " medical control ", or a role played by a base hospital. For example, in the provinces of Ontario , Quebec and Newfoundland and Labrador, many paramedic services allow primary care paramedics to perform 12-lead ECG interpretation, or initiate intravenous therapy to deliver

15678-602: The service provision. They need to remain cautious for them to stay safe in the process of providing care. There are numerous associated risks from chemical exposures in prehospital settings. The use of PPE and standard precautions are necessary to prevent harmful exposures for paramedics. Desirable implementation of the ordered processing of hazardous material and the proper decontamination process are effective strategies in combating hazard risk. Such steps are necessary to ensure fewer cases of health hazards to paramedics. Paramedics are confronted with many challenges exhibited in

15812-587: 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

15946-477: The specific case of an ambulance service being maintained by a fire department, paramedics and EMTs may be required to maintain firefighting and rescue skills as well as medical skills, and vice versa. In some instances, such as Los Angeles County , a fire department may provide emergency medical services, but as a rapid response or rescue unit rather than a transport ambulance. The provision of municipal ambulance services and paramedics, can vary by area, even within

16080-578: The state. NHTSA recognizes four levels of certification: Some states also recognize the advanced practice paramedic or critical care paramedic level as a state-specific licensure above that of paramedic. These critical care paramedics generally perform high acuity transports that require skills outside the scope of a standard paramedic (such as mechanical ventilation and management of cardiac assist devices). In addition, EMTs can seek out specialty certifications such as wilderness EMT , wilderness paramedic, tactical EMT, and flight paramedic . In 2009,

16214-469: 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. Founded in 1967, Freedom House Ambulance Service

16348-421: 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

16482-706: The threat cases are more likely to be mitigated, and the paramedics will have a better chance to provide services as required. One way of ensuring paramedics work at optimal efficiency is to provide them with protective equipment and gear to mitigate the possible risks when executing their duties. PPE keeps paramedics’ occupational risks low. Examples of PPEs include gloves , masks , and gown or specific clothing; they protect workers from physical , biological , and chemical hazards . The different types of PPE include respiratory, eye, face, and hand protection. Under respiratory protection, paramedics can use N95 masks to filter airborne contaminants . Chemical splashes are also

16616-552: 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

16750-440: The title "Paramedic" is legally protected, those utilising must be registered with the Health and Care Professions Council (HCPC), and in order to qualify for registration you must meet the standards for registration, which include having a degree obtained through an approved course. The change of entry requirements does not affect currently registered Paramedics, some of whom will still only have their entry qualification, but it

16884-528: The title of A-EMCA, or advanced emergency medical care assistant) to professional self-regulating bodies, such as the Alberta College of Paramedics. In Alberta, for instance, only someone registered with the Alberta College of Paramedics can call themselves a paramedic; the title is legally protected. Almost all provinces have moved to adopting the new titles, or have at least recognized the NOCP document as

17018-727: The weather permits and staff are available, but systems such as the Toronto EMS Critical Care Transport Program work in land ambulances. ORNGE transport operates both land and aircraft in Ontario. In British Columbia, CCPs work primarily in aircraft with a dedicated critical care transport crew in Trail for long-distance transfers and a regular CCP street crew stationed in South Vancouver that often also performs medevacs when necessary. Paramedic training in Canada varies regionally; for example,

17152-427: 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 . The early technicians with limited training, performing a small and specific set of procedures, has become

17286-469: 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

17420-650: Was powered by lead-acid car batteries , and weighed around 45 kilograms (99 lb). 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 people who were seriously injured in motor vehicle accidents on California 's freeways . Key factors contributing to victim survival in transport to definitive care such as

17554-476: 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

17688-618: Was spread among a variety of state departments. It became clear that a more unified approach to emergency and disaster medical services was needed. The Emergency Medical Services System and Prehospital Emergency Medical Care Personnel Act ( California Health and Safety Code sections 1797 et seq.) created the Emergency Medical Services Authority in 1980. This legislation (SB 125) was the culmination of several years of effort by local administrators, health care providers, consumer groups, and legislators to establish

17822-430: Was still being written. 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. While many regionally accredited community colleges offer paramedic programs and two-year associate degrees,

17956-479: 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

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