Advanced life support (ALS)

 

A paramedic has a high level of pre-hospital medical training and usually involves key skills not performed by technicians, often including cannulation (and with it the ability to use a range of drugs to relieve pain, correct cardiac problems, and perform endotracheal intubation), cardiac monitoring, tracheal intubation, pericardiocentesis, cardioversion, needle decompression and other skills such as performing a cricothyrotomy. The most important function of the paramedic is to identify and treat any life-threatening conditions and then to assess the patient carefully for other complaints or findings that may require emergency treatment. In many countries, this is a protected title, and use of it without the relevant qualification may result in criminal prosecution. In the United States, paramedics represent the highest licensure level of prehospital emergency care. In addition, several certifications exist for Paramedics such as Wilderness ALS Care, Flight Paramedic Certification (FP-C), and Critical Care Emergency Medical Transport Program certification.

Critical care paramedic

Recently studies have looked at new level of pre-hospital care. What has developed is the critical care paramedic, also called an advanced practice Paramedic in some parts of United States and Canada. These providers represent a higher level of licensure above that of the DOT or respective paramedic level curriculum. The training, permitted skills, and certification requirements vary from one jurisdiction to the next. These providers transport critically ill or injured patients from one hospital to a receiving hospital with higher level of care (ie.. cardiac catheterization, trauma services or specialized ICU services) not available at referring facility. These paramedics receive additional training beyond normal EMS medicine. The Board for Critical Care Transport Certification (BCCTPC®) has developed a certification exam for flight and ground critical care paramedics . Some educational facilities that provide this training are UMBC Critical Care Emergency Medical Transport Program or Cleveland Clinic CICP program.. Individual services such as Wake County EMS. and MedStar EMS. have developed in-house advanced practice paramedic providers. These providers have a vast array of and medications to handle complex medical and trauma patients. Examples of medication are Dopamine, Dobutamine, Propofol, blood and blood products to name just a few. Some examples of skills include, but not limited to, life support systems normally restricted to the ICU or critical care hospital setting such as mechanical ventilators, Intra-aortic balloon pump (IABP) and external pacemaker monitoring. Depending on the service medical direction, these providers are trained on placement and use of UVCs (Umbilical Venous Catheter), UACs (Umbilical Arterial Catheter), surgical airways, central lines, arterial lines and chest tubes.

Paramedic practitioner / emergency care practitioner

In the United Kingdom and South Africa, some serving paramedics receive additional university education to become practitioners in their own right, which gives them absolute responsibility for their clinical judgement, including the ability to autonomously prescribe medications, including drugs usually reserved for doctors, such as courses of antibiotics. An emergency care practitioner is a position sometimes referred to as a super paramedic and is designed to bridge the link between ambulance care and the care of a general practitioner. ECPs are university graduates in Emergency Medical Care or qualified paramedics who have undergone further training, and are authorized to perform specialized techniques. Additionally some may prescribe medicines (from a limited list) for longer term care, such as antibiotics. With respect to a Primary Health Care setting, they are also educated in a range of Diagnostic techniques.

Traditional healthcare professions

Registered nurses

The use of registered nurses (RNs) in the pre-hospital setting is common in many countries. In some regions of the world nurses are the primary healthcare worker that provides emergency medical services. In European countries such as France or Italy, also use nurses as a means of providing ALS services. These nurses may work under the direct supervision of a physician, or, in rarer cases, independently. In some places in Europe, notably Norway, paramedics do exist, but the role of the ambulance nurse continues to be developed, as it is felt that nurses may bring unique skills to some situations encountered by ambulance crews. In North America, and to a lesser extent elsewhere in the English-speaking world, some jurisdictions use specially trained nurses for medical transport work. These are mostly air-medical personnel or critical care transport providers, often working in conjunction with a technician, paramedic or physician on emergency interfacility transports. In the United States, the most common uses of ambulance-based registered nurses is in the Critical Care/Mobile Intensive Care transport, and in Aeromedical EMS. Such nurses are normally required by their employers (in the US) to seek additional certifications beyond the primary nursing licensure. Four individual states have an Intensive Care or Prehospital Nurse licensure that is above the Paramedic. Many states allow registered nurses to also become registered paramedics according to their role in the emergency medical services team. In Estonia 60% of ambulance teams are led by nurse. Ambulance nurses can do almost all emergency procedures and administer medicines pre-hospital such as physicians in Estonia. In the Netherlands, all ambulances are staffed by a registered nurse with additional training in emergency nursing, anaesthesia or critical care, and a driver-EMT.  In Sweden, since 2005, all emergency ambulances should be staffed by at least one registered nurse since only nurses are allowed to administer drugs. And all Advanced Life Support Ambulances are staffed at least by a registered nurse in Spain. In France, since 1986, fire department-based rescue ambulances have had the option of providing resuscitation service (reanimation) using specially trained nurses, operating on protocols, while SAMU-SMUR units are staffed by physicians and nurses.

Physician[edit]

There are many places in Europe, most notably in France, Italy, the German-speaking countries (Germany, Switzerland, Austria), and Spain where the model of EMS is different, and physicians take a more direct, hands-on approach to pre-hospital care. In France, Italy, and Spain, response to high-acuity emergency calls is physician-led, as with the French SMUR teams. Paramedics do not exist within those systems, and most ALS is performed by physicians. In the German-speaking countries, paramedics do exist, but special physicians (called Notarzt) respond directly to high-acuity calls, supervising the paramedics ALS procedures directly. In these countries, paramedics may perform many procedures under their Notfallkompetenz (emergency competence), meaning that they may autonomously perform treatments, such as defibrillation or administering drugs, if there is no physician on scene, and a life-threatening condition is present, otherwise they may only act on the physicians instructions.Some systems - most notably air ambulances in the UK. will employ physicians to take the clinical lead in the ambulance; bringing a full range of additional skills such as use of medications that are beyond the paramedic skill set. The response of physicians to emergency calls is routine in many parts of Europe, but is uncommon in the UK, where physicians are generally tasked to high priority calls on a voluntary basis. Within the UK a sub-speciality of Pre-Hospital Care is being developed for Doctors, which would allow training programs and consultant posts to be developed in this one area of practice. This hands-on approach is less common in the United States. While one will occasionally see a physician with an ambulance crew on an emergency call, this is much more likely to be the Medical Director or an associate, inducting newly trained paramedics, or performing routine medical quality assurance. In some jurisdictions adult or pediatric critical care transports sometimes use physicians, but generally only when it appears likely that the patient may require surgical or advanced pharmacologic intervention beyond the skills of an EMT, paramedic or nurse during transport. Physicians are leaders of medical retrieval teams in many western countries, where they may assist with the transport of a critically ill, injured, or special needs patient to a tertiary care hospital, particularly when longer transport times are involved. In these cases the physicians role is extended to ensure the highest level of care is provided throughout the transport and diagnosis of serious medical conditions.