KEY CONCEPTS:
Upon completion of this topic, it is expected that the reader will understand these following concepts:
• The profession of paramedicine combines aspects of public health, public safety, and health care
• Standards and scope of practice define the Paramedic’s knowledge, skills, and attitudes
• The Paramedic’s role is as a healer, clinician, and teacher
• Quality assurance, Quality improvement, and continuing education enhance both the Paramedic’s individual practice and that of the profession as a whole
• The Paramedic is a physician extender through stewardship, leadership, and followership
CASE STUDY:
Traffic was slowed around the accident site. As the two teens drove slowly by, each looked at the Paramedics who were providing and directing care of the victims. The first teen stated, "They sure looked like they knew what they were doing." The second teen added, "I wonder what else they do."
OVERVIEW
Although paramedicine is a relatively young profession compared to many others, it has found its footing as a unique part of the healthcare system. The Paramedic’s role has evolved from simply responding to emergencies to now practicing an expanded scope of practice as a physician extender. In this way, the Paramedic has proved to be a vital part of the public health and safety team. This topic not only examines the origins of paramedicine but also how national education standards and accreditation of educational programs coupled with professional organizations have helped to validate paramedicine as a profession. The topic also examines the Paramedic’s core values and his or her role as healer, clinician, and teacher. As the Paramedic’s scope of practice and community responsibilities continue to develop, quality assurance, quality improvement, and continuing educational programs need to be established. The Paramedic’s independent and interdependent role as a physician extender relies on leadership and stewardship.
What Is Paramedicine?
Paramedicine is a special subset of medicine that Paramedics provide in the out-of-hospital setting. Paramedics, as allied healthcare professionals, practice paramedicine under often austere conditions and with a minimum of equipment. Paramedic practice is both independent as well as interdependent. The universe of independent Paramedic practice includes disaster planning, response readiness, scene management, and emergency vehicle operations. Collaboratively, Paramedics work interdependently with emergency physicians to bring the highest level of medical care outside of the hospital.
While Paramedics traditionally have provided emergency care as part of the emergency response system, Paramedics also provide care during transportation between medical facilities. Interfacility patient care often involves a high level of medical complexity and requires education above that of the entry-level Paramedic.
Paramedicine is positioned at the intersection of health care, public health, and public safety. Owing its existence to each, the Paramedic is cross-trained in each of these areas. As a result, a synergy occurs among the knowledge from these three areas and the result is paramedicine, a unique body of knowledge which is exclusive of its origins.
More than a vocation, paramedicine involves extensive educational preparation, typically at a collegiate level, to attain the specialized knowledge necessary to become a Paramedic. Paramedic education is usually attained in an educational program that is accredited by a body which includes professional Paramedics.
Paramedicine is also an applied science. To attain proficiency at patient care skills and apply the knowledge gained to care of patients, Paramedic students learn and work under the watchful eye of preceptors. Upon completion of a program of study, Paramedics complete professional certification examinations and become licensed to practice paramedicine. All Paramedics understand the importance and the necessity of giving back to their profession through teaching Paramedic students.
The practice of paramedicine, like the practice of medicine, is constantly evolving. Professional Paramedics incorporate and apply new information and technologies in their practice. Through programs of competency assurance and professional development, offered in continuing education programs, the Paramedic stays current with the profession.
The Paramedic’s professional identity revolves around the voluntary assumption of certain roles and responsibilities and a code of ethics. Once Paramedic status is attained, that person is a Paramedic and, regardless of other roles the person may have in a lifetime, will always see himself as a Paramedic.
The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.
—William Osler, MD
The professional Paramedic has many roles, the first of which is as a healer. Healing is an attempt to mollify the effects of disease. In many instances the Paramedic is unable to effect a cure and strives instead to relieve pain and suffering. Healing is a process of helping people physically, mentally, and spiritually endure their illness. As one of the healing professions, when the practicing Paramedic demonstrates empathy, respect, and a genuine interest in the patient, the Paramedic is seen as a compassionate caregiver—a healer. This ability to help the patient in distress to heal while providing medical care could be seen as the art of paramedicine.
While Paramedics rarely cure a disease, the practice of paramedicine is also based, in part, on the science of medicine.12 The science of medicine focuses on cure and medical research is continually improving the treatment of patients with diseases. In turn, the medical treatments that Paramedics provide are based, to the extent possible, on medical research. A professional Paramedic always keeps abreast of the medical science which has an impact on the practice.
Paramedics are also stewards. As a shared practice that originates in medicine, Paramedics are responsible for maintaining the ideals of medicine and to practice in a manner that would bring honor to themselves and their physician colleagues. The right to practice paramedicine is given to Paramedics by physicians who understand the importance of collaborative practice.
As members of the healthcare team Paramedics are also leaders. Paramedics are not leaders by virtue of their position but by their ability to affect the behavior of other members of the team to accomplish the goal of patient care. As a leader, the Paramedic may have to take on the role of teacher or patient advocate, but in every instance the patient’s welfare is foremost in the Paramedic’s mind.3
As the leader, the Paramedic also understands the importance of followership. A Paramedic’s adherence to the physician’s orders, as well as those of other authority figures, is an example of followership. Followership is not offered begrudgingly but instead willingly, with an understanding of the importance of teamwork for patient care.
PROFESSIONAL PARAMEDIC
The role of patient advocate encompasses all of the Paramedic’s other roles and responsibilities.
Hallmarks of a Profession
In the past, Paramedics were considered auxiliary healthcare providers, unlicensed care providers who received the majority of their training "on the job" (OJT) and were not considered to be healthcare professionals. Classic examples of healthcare professionals are physicians, nurses, and physician assistants. These groups are considered professional because they meet certain criteria to be considered a profession. Paramedics have not yet met those criteria. However, the field of paramedicine is in the process of professionalization.
Some of the criteria for consideration as a healthcare professional were discussed in the fourth report of the Pew Health Professions Commission entitled, "Recreating Health Professional Practice for a New Century."4 The section entitled, "Professional Characteristics of Allied Healthcare Providers" describes what is needed for a group to be considered an allied healthcare provider.
To be considered an allied healthcare provider, Paramedics would first need extensive educational preparation. This type of education is typically provided in a college or university environment in accredited educational programs.
Table 1-1 Qualities of a Profession
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Extensive educational preparation |
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Accreditation of educational programs |
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Mentoring |
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Certification |
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Licensing |
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Professional development |
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Professional societies |
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Code of ethics—professional boundaries |
During their education, Paramedic students would need professional models, or mentors to guide them along in their educational development. Upon successful completion of the original education, the Paramedic’s rite of passage into the profession would be certification and licensure. Once in the field, the practicing professional Paramedics would be expected to maintain their education through competency assurance and professional development.5 Paramedics would also be expected to contribute to the profession through active participation with fellow Paramedics in an association or society. Central to these professional associations or societies is a code of ethics which helps define the profession. Many qualities are common in all professions (Table 1-1).
Currently Paramedics are required to obtain extensive educational preparation to acquire a unique body of knowledge. An increasing number of Paramedic programs are being offered in accredited programs provided at postsec-ondary schools where Paramedic students also learn from experienced preceptors during an internship. Plus, there is a growing trend toward licensing Paramedics. These efforts, and others, will help to shape and develop the Paramedic profession.
CULTURAL/REGIONAL DIFFERENCES
No national exam serves as a culminating point for entry into the profession of paramedicine as does the NCLEX for professional nursing. A tapestry of county, regional, and state requirements often create difficulties in transferring from one geographical area to another.
To assist current and aspiring healthcare professionals, the Pew Health Commission listed what were felt to be the 21 competencies that healthcare professionals needed to aspire to in the twenty-first century. Some of these are especially germane to Paramedics (Table 1-2).
Table 1-2 Partial List of the 21 Competencies for Healthcare Professionals for the Twenty-First Century from the Pew Health Commission
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Embrace a personal ethic of social responsibility and service |
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Exhibit ethical behavior in all professional activities |
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Provide evidence-based clinically competent care |
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Integrate population-based care in services into practice |
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Improve access to healthcare for those with unmet health needs |
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Provide culturally sensitive care to a diverse society |
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Use communication and information technology effectively and appropriately |
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Work in an interdisciplinary team |
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Practice leadership |
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Contribute to continuous improvement of the healthcare |
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system |
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Continue to learn and help others learn |
Education Systems
Key to a profession is the educational preparation required to enter that profession. In the past, the DOT National Standard Curriculum has served as the basis for EMS education. Since the creation and adoption of the first EMT-A National Standard Curriculum (NSC) in 1969, the DOT NSC has served as both curriculum and a scope of practice in that EMS lacked any other unifying documents. The document which will replace the NSC is the National EMS Education Standards. The standards, together with the national core content and national scope of practice, identify the Paramedic’s knowledge, skills, and attitudes.
The National EMS Education Standards (NEMSES) provide the foundation for that final terminal objective of every EMS education program—the graduation of a competent entry-level Paramedic.6
Commission on Accreditation of Allied Health Education Programs
To ensure that Paramedic education programs adhere to these educational standards, the Commission on the Accreditation of Allied Health Education Programs (CAAHEP) charges the Committee on Accreditation of Educational Programs for the EMS Professions (CoAEMSP) to investigate and report to CAAHEP.
Accreditation of a Paramedic program is evidence of a satisfactory report from the CoAEMSP having been furnished to CAAHEP. At present, CAAHEP accredits over 2,000 educational programs in 19 healthcare professions.
Beginning in 2012, the National Registry of Emergency Medical Technicians will only permit those individuals who have completed their education in an accredited Paramedic education program to seat for the Paramedic national certification examination.
National Registry of Emergency Medical Technicians
The culmination of a Paramedic education should be certification. A certification is a formal process in which an outside organization, often an organization that represents the profession or the professional association, verifies through written and/or practical examination the competency of an individual who wishes to enter the profession. This process seeks to ensure that the individual possesses the minimum level of knowledge and skill required to practice that profession.
The National Registry of Emergency Medical Technicians (NREMT) presently provides a certification process of practical testing and written examinations for the certification of Paramedics. Successful completion of the National Registry testing demonstrates that the Paramedic has demonstrated a minimally acceptable level of proficiency in the core elements.
The National Registry was initiated by recommendation of the American Medical Association’s (AMA) Committee on Highway Traffic Safety, chaired by Dr. Oscar Hampton Jr. The committee included notable EMS authorities such as Dr. J.D. "Deke" Farrington, author of the influential article "Death in the Ditch." The National Registry of EMT was formed in June 1970 and—under the leadership of its first executive director, Rocco V Morando—proceeded to meet its mission "to certify and register EMS professionals throughout their careers by a valid and uniform process to assess the knowledge and skills for competent practice."
National Association of Emergency Medical Technicians
The EMS profession is relatively young compared to other healthcare professions. While EMS has roots in the past, the emergence of EMS as a profession has occurred in less than four decades. Nevertheless, EMS has strived to meet its ideals and become recognized as a profession.
One of the other attributes of a profession is a professional organization or society that speaks on behalf of the members. The National Association of EMT (NAEMT) is a professional organization, founded in 1975, whose mission is to represent the views and opinions of all prehospital care providers. As the voice of the profession, it has been leading efforts to help professionalize EMS. Through its leadership, the NAEMT has been influential with the advancement of EMS as an allied healthcare profession. The NAEMT has liaisons with at least 28 federal agencies and professional organizations with interests in EMS. That list of collaborating organizations includes the American College of Emergency Physicians (ACEP), the National Association of EMS Physicians (NAEMSP), the Advocates for EMS, the National Registry of EMT (NREMT), the International Association of Firefighters (IAFF), the International Association of Fire Chiefs (IAFC), the Emergency Nurses Association (ENA), the American Red Cross (ARC), EMS for Children (EMSc), the Federal Emergency Management Agency (FEMA), the National Rural Health Association (NRHA), and the Commission on the Accreditation of Ambulance Services (CAAS), to name a few.
National Institute of Medicine Report
The landmark National Institute of Medicine Reports entitled "EMS at the Crossroads" and "Hospital Based Emergency Care: At the Breaking Point," released in 2006, spoke of the dysfunctional and fragmented emergency services in the United States.7 These reports encouraged standardization of emergency services through processes such as national accreditation of the Paramedic programs, national certification of Paramedics, and organized efforts at improving the delivery of patient care through cooperation with other healthcare professions.
Core Values
The clinical care provided by Paramedics, guided by evidence-based science, is dictated by protocols, guidelines, and algorithms. But the human side of paramedicine—that aspect of EMS which makes it part of the patient care realm—is dictated by another set of rules, the core values of a Paramedic professional. Paramedics must possess these core values, which complement and enhance their clinical skills and medical knowledge. Otherwise, Paramedics will be ineffectual as patient care providers.
The key professional attribute and the first core value of a Paramedic is caring. Caring is an expression ofconcern toward the patient by the Paramedic and is foundational to the Paramedic-patient relationship. To practice caring, some Paramedics have been taught to use the PEARLS model advanced by the American Academy on Physician and Patient. The letters in the PEARLS mnemonic stand for partnership, empathy, apology, respect, legitimization, and support. These are the qualities that provide for a strong Paramedic-patient relationship.
While in the past most patients willingly accepted a physician’s advice without question, patients today are less tolerant of this paternalistic approach. Patients now want to be knowledgeable about their choices and to be involved in their healthcare decisions. They want to partner with their healthcare provider. Paramedics who involve patients in their own care, in a partnership, are demonstrating an acceptance of the patient’s wishes to be involved and in control. Paramedics who involve patients in decisions about their own care empower the patients to take more responsibility for their own health. This Paramedic-patient cooperation tends to improve the patient’s overall satisfaction with the care provided by the Paramedic.
Another key to quality patient care is empathy. Empathy is an emotional understanding of the patient’s feelings; to be able to understand what it is like to walk in the other person’s shoes. Some refer to empathy as a good bedside manner. Paramedics can demonstrate their empathy through both action and words.
Like the teachable moment—that point in time when the student is most susceptible to learning—empathy is best expressed when the provider recognizes the presence of strong emotion and then responds to the patient in a supportive manner. To be supportive, all the Paramedic need do is imagine the feeling the patient is experiencing, be it anger or fear or hopelessness, and then acknowledge those feelings to the patient in a simple statement such as, "This must be difficult for you." This simple offer of respect and support will be appreciated by the patient.
Sympathy is the quality of suffering with the patient. While empathy is a quality to be practiced, sympathy can interfere with the patient-provider relationship. Sympathy is lending an emotional quality to the relationship that is neither wholesome nor professional and which can lead to burnout. The Paramedic should strive to understand the patient’s feelings (empathize) but not take on the patient’s feelings (sympathy).
Caring implies emotional vulnerability on the part of both the patient, who confides in the Paramedic, and the Paramedic, who is trying his best to provide care, often under trying circumstances. To be truly caring, the Paramedic must be willing to also share his mistakes with the patient and apologize if necessary.
While the thought of apologizing for an error may seem abrasive or unwise to some, physicians and Paramedics are increasingly accepting of the need to apologize. Simply stated, no matter how skillful or knowledgeable the Paramedic, mistakes will be made. The Institute of Medicine (IOM) 1999 report estimated that between 44,000 and 98,000 patients will die while in the hospital from mistakes.8 Mistakes are a part of the practice of paramedicine and each mistake represents an opportunity for improvement. The Paramedic’s acceptance of the mistakes and willingness to apologize will be important to the patient’s satisfaction with care.9 Whenever a professional standard of care is breached, or the outcome is unwanted or unexpected, a caring Paramedic admits the error and demonstrates caring when he apologizes.
The first step whenever an error is encountered is to investigate why the error occurred. If there is no immediate explanation forthcoming, then the Paramedic should explain to the patient that an error occurred and, if appropriate, explain that "I will find out why" and get back to the patient later with an answer.
If the decision is made to apologize, the Paramedic should choose an appropriate time and place—perhaps after patient care has been turned over at the emergency department—and explain the situation, stating that an error has been made. A skillful Paramedic listens to the family’s response and answers their questions thoughtfully and after a moment’s reflection.
Fundamental to the Paramedic-patient relationship is respect for the patient. Respect is based upon a nonjudgmen-tal attitude toward the patient, regardless of the personal circumstances. While many Paramedics are aware of prejudices about race or religion, the problem of economic prejudice is less recognized. Regardless of the social status or economic position that a patient holds at any one moment, the Paramedic should respect the patient as a person in need of help and worthy of care.
On occasion some Paramedics have difficulty understanding the patient’s concerns, and may even cite "9-1-1 abuse" when speaking about these patients. Regardless of the Paramedic’s attitude, these patients have a concern that prompted them to call for emergency medical services. The caring Paramedic listens and seeks to understand the patient and the patient’s concern, regardless of how seemingly insignificant the problem. This process of legitimization supports the patient and demonstrates caring. A patient who is put at ease is more cooperative with care and has a more positive regard for the Paramedic.
Finally, the Paramedic demonstrates caring and compassion by offering the patient support and acting as a patient advocate. Being a patient advocate is important in a chaotic world where people are "lost in the process" and "treated like a number."
Inherent within interpersonal communications is the concept of diplomacy. A thoughtful consideration of the words spoken, to ensure that the message spoken does not have an unintended meaning, improves interpersonal understanding and, ultimately, patient care.
While the science of emergency medical care can be learned from a topic, the art of emergency medical service— combining the previously stated qualities in an effective manner—is best learned by practice in the field with a master Paramedic. A professional mentor can help with the process of socialization needed to create a professional Paramedic. A novice Paramedic subjected to intense socialization at the hands of seasoned professionals within a healthy EMS culture can quickly mature into a professional Paramedic.
