Roles of a Paramedic
A Paramedic assumes many roles during the course of a career. The primary roles are those of healer, clinician, and patient advocate. As the Paramedic’s practice evolves, the Paramedic may become involved as a researcher or a teacher. These changing roles keep a Paramedic engaged with the profession and continuously striving to improve his practice.
Healer
The Paramedic’s primary role is that of healer. A healer is a person who supports another during illness. From the old English "Haelan" meaning to make whole, sound, and well, the Paramedic, as a healer, supports the patient, both physically and spiritually, through an illness or injury.
The role of the healer revolves around showing compassion. Dr. Bernard Lown, noted cardiologist and Nobel Peace Prize winner, states in his topic The Lost Art of Healing that healing involves two aspects: preserving the personhood of an individual and providing comfort measures.
By its nature, illness is an attack upon an individual’s sense of person, the individual’s personhood. Illness threatens the patient’s quality of life and perhaps even the patient’s life itself. Moreover, illness is something that the patient has limited ability to prevent and little control over once it occurs. As a result of illness, the patient may feel helpless. This sense of helplessness leads to suffering.
To help reduce suffering, the Paramedic need only show compassion. Compassion is an awareness of another’s suffering. In some cases it only takes the Paramedic’s concerned presence (presencing) to help alleviate the suffering. The importance of presencing is exemplified by the common feeling often voiced by others that no one wants to die alone. By merely being there and showing compassion, the Paramedic helps to support the patient and, specifically, helps the patient validate himself and his sense of personhood.
Illness also brings pain. The Paramedic, as healer, can provide a range of comfort measures to the bedside. In some cases that comfort measure is in the form of pharmaceutical pain management. But in almost every case the Paramedic’s therapeutic use of touch helps to relieve the patient’s pain and provides comfort. Therapeutic touch has long been recognized by nursing as an effective treatment for pain. Therapeutic touch involves one-on-one attention and human touch.
Clinician
A clinic is a place dedicated to the diagnosis and care of a patient. A clinician is the person who works in that place. It could be said that the Paramedic’s clinic is the back of an ambulance, a place where the Paramedic assesses and diagnoses a patient’s ailment.
A Paramedic’s diagnosis is a broad diagnosis made after an assessment. During the assessment the Paramedic ascertains a symptom complex. This symptom complex is simply a list of abnormal conditions found by the Paramedic during the history of the present illness and the physical examination. The Paramedic then, in turn, takes the symptom complex, compares it to his knowledge of disease, and matches it to a known symptom pattern associated with a disease to arrive at a diagnosis.
With only crude medical instruments and a limited time for history taking, the Paramedic’s diagnosis, sometimes called a field diagnosis, must be broad and comprehensive. Typically a Paramedic makes a diagnosis of a syndrome, a group of signs and symptoms that signifies a specific disease, or of a primary disorder of homeostasis, such as hypoxia.
As a clinician, the Paramedic’s first responsibility is to treat disorders of homeostasis which threaten the patient’s survival. The brain’s survival is paramount. The three essential conditions for the brain’s survival are adequate oxygen, glucose, and perfusion. If the brain lacks any of these three conditions, then the patient has a fundamental disorder of cerebral function and manifests an altered mental status.
The approach to the assessment and treatment of these disorders is exemplified by the mnemonic ABC. The patient is assessed for hypoxia, hypoperfusion, and hypoglycemia. While this description is technically accurate, it is a gross simplification of a process which is expanded upon and discussed throughout this series.
The Paramedic, as clinician, keeps one invaluable rule foremost in the mind when treating the patient. That rule, simply stated, is "do no harm." While some harm will always come from a treatment or drug (e.g., the pain of a needle), the harm is outweighed by the benefit that the treatment or drug will have for the patient. The rule "do no harm" is intended to cause Paramedics to pause and consider every treatment intervention before proceeding.
The decision to treat in the field is multifactorial. In some instances it is more prudent to withhold certain treatments until arrival at the hospital where more experienced physicians can make the judgment about which treatments to initiate. At other times, delaying treatment in the field can be detrimental to the patient.
The Paramedic, as clinician, understands that medicine is a practice, meaning the science of medicine must be matched to the patient to try to obtain a maximum benefit for the patient. In some instances that match is not perfect. Learning the right time to perform specific procedures or administer particular medication is often a function of trial and error. It takes practice.
The Paramedic, as clinician, understands that the practice of medicine is first and foremost about the patient. The Paramedic understands that while the technology to treat the patient is becoming truly amazing, the priority remains to treat the patient as a person. The Paramedic understands that the love of technology and the science of medicine (philotechnia) comes second to caring for the person (philanthropia).
Expanded Scope of Practice
The traditional role of a Paramedic has been in the out-of-hospital setting responding to medical emergencies. But as necessity has required, the Paramedic’s role has expanded in some limited situations and the Paramedic’s scope of practice has expanded as well.
Driven by the increasing specialization of hospitals (i.e., trauma centers), interventional cardiology centers, stroke centers, children’s hospitals, and so on, and accelerated by the nursing shortage, more Paramedics are becoming involved in specialty care transport (SCT). Paramedics who perform SCT have training above that of the typical Paramedic. The flight medic is an example of a specially trained Paramedic who performs SCT.10
In some other circumstances, such as rural communities, or under special conditions such as an epidemic, it may be appropriate to give Paramedics an expanded scope of practice to supplement existing healthcare resources.
The American College of Emergency Physicians, in a position paper on expanded scope of practice, specifies several conditions that must be met before Paramedics can perform an expanded scope of practice.12 ACEP maintains that all expanded scope of practice must be closely monitored, with intimate physician involvement and a rigorous quality assurance process that has standards and mechanisms for remediation. ACEP, in its position paper, further states that such expanded scope of practice must fulfill a community need, usually based on an assessment and plan of action, and that the practice is legally permissible.
Self-Evaluation and Continuous Quality Improvement
The Paramedic, as clinician, is always trying to improve the practice of paramedicine. This is best accomplished by critical self-evaluation and planned action. For example, an often quoted goal of EMS is the patient’s satisfaction. Patient satisfaction may result from many factors including the provision of high-quality emergency medical care, timeliness of response, or respect for the patient’s rights. An EMS system objective would be an eight-minute response in 90% of calls for EMS. It might also be in response to a patient demand for a timely response. If that objective is met then, to some extent, patient satisfaction with EMS should be higher.
While an EMS system may periodically look at certain practice parameters, a superior EMS system is always in a process of review and re-engineering, trying to refine the process and improve the delivery of EMS. This approach is called continuous quality improvement (CQI) and involves a process that can be summarized as plan-do-check-act (PDCA). This PDCA cycle is different than simply verifying compliance with established standards, or quality assurance (QA), because it has an action component.
Any system of self-analysis, whether it is QA/CQI or others, is dependent on the data collected. These information systems can be real-time (i.e., direct observation of skills or performances in the field), but are often done retrospectively, after the fact, by a chart audit. For a chart audit to be reliable and dependable, it is important that Paramedics accurately and completely describe the care given. As the saying goes, "If it wasn’t written down then it didn’t happen."
Continuing Medical Education
Another responsibility of a professional Paramedic as clinician is to stay current with the state of the art. This is best accomplished through continuing medical education which culminates in periodic recertification. Paramedics also have a responsibility to re-register every two or three years. The re-registration is intended to ensure the public that the Paramedics that serve them have remained competent as Paramedics.
Figure 1-1 EMS journals are a means to obtain information about the state of the art.
However, the Paramedic understands the necessity of not only maintaining minimal skills and an adequate knowledge base, or competency assurance, but the need to continue to remain current with the state of the art. Paramedics are expected to keep abreast of new developments in the field of medicine as they pertain to EMS through involvement in professional development.
Attendance at state and national EMS conferences as well as attending regional workshops help ensure that the Paramedic is continuing to develop and provide high-quality emergency medical care. Alternatively, Paramedics often turn to their medical directors for guidance and education on new technologies. Another way to keep up with the profession is reading EMS trade journals (Figure 1-1). The best EMS trade journals have research that is peer-reviewed or articles that are refereed.
Whenever research has been peer reviewed, that means the article or research was critically appraised by experts in the field for validity. To be valid, the research has to objectively support its conclusion. In other words, the research must not be personal opinion, contain exaggerated statements, or make unjustifiable claims.
However, articles are not peer reviewed per se but rather are refereed. Typically an editor will distribute an article to a panel of expert Paramedics, in this case, and these expert Paramedics offer input. They edit the article and act as referees. Then the article is returned to the author and the author is allowed to revise the article before re-submission. Often the comments offered by these referees cite current research or best practices.
The commitment made by all Paramedics when they attain that first certification is to remain current with the profession through life-long learning.
Researcher
EMS practice in years past was based upon either in-hospital practice, which sometimes did not fit into the prehospital environment, or anecdotal experience. This approach has led to a great deal of concern regarding the effectiveness of EMS by some. To counter these claims, Paramedics have turned to an evidence-based approach to the practice. Changes in practice are now driven by research and the practice is becoming more reliable and valid in the process.
PROFESSIONAL PARAMEDIC
The professional Paramedic is interested in research because it offers the opportunity to improve the efficiency of paramedicine.
Teacher
Paramedics, in an effort to reduce injury and illness, have started to educate the public. These opportunities to educate the public sometimes occur during an emergency call, on a one-to-one basis, or in public education programs.
To be effective, this education must occur when the person, or the public, is ready to learn. This is called the teachable moment. For example, a campaign to wear seat belts may have more impact immediately following a fatal motor vehicle collision involving teenaged drivers. At that moment the public is sensitive to preventable death from motor vehicle collisions.
PROFESSIONAL PARAMEDIC
A newer role for the Paramedic is that of health educator.
Public Education
Public education is one means of garnering public support while simultaneously providing the public with the information they need about injury and illness prevention. A model public education system called PIER was developed by the National Highway Traffic Safety Administration (NHTSA).13 PIER stands for public information, education, and relations, and incorporates the three aspects of public education.
The first aspect, public information, pertains to information regarding people and events that the media traditionally communicates to the public. Many EMS agencies have a public information officer (PIO) whose responsibility is to interface with the news media and to provide public information. The PIO must be cautious about not revealing restricted personal health information (PHI), a violation of the Health Insurance Portability and Accountability Act (HIPAA) regulations, while simultaneously providing the news media the information that it is entitled to due to the freedom of the press.
Table 1-3 Public Education Activities
|
Public Information |
|
• Press conferences |
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• Newspaper announcements about weekly EMS activity |
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• Annual reports to government boards or councils |
|
Public Education |
|
• CPR classes |
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• Life-saving classes |
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• Pediatric drowning education |
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• Elderly fall prevention classes |
|
Public Relations |
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• Open house |
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• Blood pressure clinics |
The second aspect of PIER is public education. All education is an attempt to change behaviors. Public education, from an EMS perspective, is an attempt to change the public’s behavior toward medical emergencies. Examples of public education programs include CPR classes for citizens or public access defibrillation (PAD) for school officials.
The final aspect of PIER is public relations. Public relations is less an effort to educate the public (though there can be overlap) as it is to garner the public’s support of Paramedics. The public’s opinion of Paramedics can be directly translated to support for new programs or support of public funding. The Paramedic is involved in a number of public education activities (Table 1-3).
Patient Advocate
Finally, the professional Paramedic is a patient advocate. Being a patient advocate means that the Paramedic defends and supports the patient’s rights to health care. Whenever a Paramedic acts to help a patient obtain needed health care he is acting in the advocacy role. A Paramedic is also acting in an advocacy role when she supports, through constructive argument, the need for equipment that will improve patient care. Some would see reporting child abuse as a Paramedic acting in an advocacy role as well.
Paramedics as Physician Extenders
While physicians are educated in medical schools, it is the state, through licensing legislation, that authorizes the physicians to practice medicine. Most states have state statutes, called a medical practice act, that define medical practice.
Many of these medical practice acts have a reference to physician extenders, allied health professionals who work under the license granted to the physician. Paramedics, as physician extenders, are among those allied healthcare professionals who are permitted to perform limited medical procedures while under the supervision of a licensed physician.
Stewardship
Because Paramedics work under the physician’s license, paramedicine is a shared practice with physicians. However, often a physician is not present when the Paramedic is taking care of the patient. Nevertheless the Paramedic is still representing the physician and the responsibilities of medicine.
Therefore, in the absence of the physician, the Paramedic shares the physician’s responsibilities, including veracity, fidelity, beneficence, avoidance of malfeasance, and justice. Whenever a Paramedic upholds noble traditions of medicine the Paramedic is acting in the role of a steward. Stewardship is a weighty responsibility for the Paramedic. A Paramedic’s failure to properly conduct himself, as a physician would, often leads to conflict between the Paramedic and physician and loss of medical privileges.
Leadership
As the highest level of out-of-hospital EMS provider, Paramedics are often thrust into the leadership role by virtue of their education. This traditional form of top-down management (vertical leadership) was common in the immediate post-World War II business world. It can be visualized as a pyramid with a distinctive chain of command.
However, enlightened Paramedics as leaders seek to "flatten the pyramid" and work toward linking, or networking, with the members of a public safety team. This horizontal leadership style demonstrates that the Paramedic values the contributions of every team member. Horizontal leadership emphasizes an "out and back" line of communication instead of an "up and down" line of communication and can be visualized more like a wagon wheel.
In an information intensive era, horizontal leadership is an effective technique for knowledge management. Nevertheless, there still needs to be a nexus for control. Traditionally the Paramedic assumes that role, offering common direction and a strong vision to fellow EMS team members as well as other public safety partners.
The Paramedic, as leader, needs to have a sense of direction and a strong personal vision of paramedicine. He must also constantly reflect upon the values common to a professional Paramedic (ethics) and work to incorporate those values into daily practice.
Besides being a model of ethical behavior, the Paramedic as a leader is also a coach. As coach the Paramedic teaches others, or trains the team, to work together to reach a common goal.
The qualities of a good leader can be summed up in the 5 "C’s": competence, command presence, choreography, communications, and conflict resolution. Competence goes beyond merely being technically proficient at skills and instead means having operational competence. Operational competence includes knowing how the various team members interact, knowing an organization’s policies and procedures, and possessing situational awareness.
The Paramedic, as leader, has situational awareness. He can read the scene and can detect both opportunity and threat. These opportunities include teaching moments, times for the team members to learn, without risk to either the team’s or the patient’s safety. This skill cannot be easily learned from topics but rather is a result of witnessing master medics function in the field.
Another quality of a good leader is command presence. Command presence can be defined as that ability to present oneself as the person of authority. The Paramedic’s authority flows, in part, from the respect that the team has for the medical director and the Paramedic’s role as the medical director’s steward.
Outwardly, the Paramedic’s appearance can demonstrate confidence, a key command trait. A clean pressed uniform and the "tools of the trade," such as a stethoscope, give the Paramedic the appearance of a medical professional. A professional appearance, along with a professional attitude, can substantially improve one’s command presence.
Confidence can also be manifest in one’s behaviors. The confident Paramedic walks purposefully toward the patient with an eye toward the patient as well as the surrounding environmental, i.e., situational awareness. Confidence is further demonstrated in purposeful speech with a low tone. Instead of yelling into the scene, instructions are pointedly given to individuals by looking toward that individual and speaking an unambiguous message in a directive manner.
The next quality of a Paramedic leader is the ability to organize the team’s efforts in order to deliver appropriate interventions in a timely manner. This skill could be described as choreography. While algorithms are helpful with organizing patient care, acting almost like a pre-plan, on-scene conditions and other variables make it imperative that the Paramedic take an active role in leading the team down the treatment pathway.
To be truly effective, the Paramedic, as leader, must also be a strong communicator. A key to success in teamwork is possessing excellent communication skills. The Paramedic must be articulate with both patients and family, speaking to them in terms that they understand while still being able to be conversant with fellow healthcare professionals, most notably the emergency physician, in terms that they will understand.
It is inevitable that disputes about patient care will occur among team members. Without the authority given in a traditional chain of command, the Paramedic must be masterful at conflict resolution in order to maintain order and control. In high stress situations (i.e., those with a high life hazard), it may be necessary for the Paramedic to assert authority, issue a command, and offer to review the call later with the team. In those cases it is important for the Paramedic to institute an "after action review" and allow all parties to express their viewpoints and vent their emotions. But if time permits, and it is not disruptive to patient care, the Paramedic may elect to listen to the suggestions of other team members offered in civil discourse. During these teachable moments learning can occur for all involved, including the Paramedic leader.
Followership
Consistent with the concept of leadership is followership. Followership is a willingness to follow a leader’s direction and to support the mission, putting aside personal ambitions. Every leader is a follower at some level. Inherent in the definition of paramedicine is the willing submission to medical command. But followership is more than submission.
A Paramedic, as follower, understands the mission (patient care) and is dedicated to that mission. The Paramedic, as follower, understands the team’s need for compliance (team play) in order to achieve the team’s common goals. The good follower puts the needs of the team and the patient above one’s own needs.
A Paramedic, as follower, makes timely recommendations to the leader. That includes respectfully disagreeing with the leader when need be, if that is what is in the best interests of the team and/or the patient.
A Paramedic, as follower, sets the example for others by understanding the leader, anticipating the orders of the leader, and complying with those orders. Perhaps more importantly the Paramedic, as follower, knows when to take appropriate action when no orders are forthcoming.
Finally, the Paramedic, as follower, keeps the information flowing to the leader and does not horde vital information. Through clear communications, all members of the team can provide the highest quality of care.
Conclusion
Paramedicine is a pattern of thinking and behaviors, that outward manifestation of thinking, that is consistently applied in varying situations until a practice has been achieved. The art of paramedicine is the ability to apply that practice while maintaining focus, using one’s wits and creative abilities.
KEY POINTS:
• Paramedic practice is both independent, encompassing specialized prehospital practices, and interdependent, through a working relationship with emergency physicians.
• The Paramedic is cross-trained in health care, public health, and public safety.
• The National EMS Education Standards, together with the national core content and national scope of practice, identify a paramedic’s knowledge, skills, and attitudes.
• Professional organizations or societies, such as the National Association of EMT (NAEMT), provide a voice for the profession and have been leading efforts to professionalize EMS.
• The landmark National Institute of Medicine Reports entitled "EMS at the Crossroads," and "Hospital Based Emergency Care: At the Breaking Point," released in 2006, encouraged changes in the delivery of patient care.
• Caring is an expression of concern toward the patient and is foundational to the Paramedic-patient relationship.
• A Paramedic may assume the role of healer, clinician, and patient advocate.
• During the assessment, the Paramedic ascertains a symptom complex.
• The Paramedic, as clinician, keeps one rule in mind when treating the patient: do no harm.
• Roles and responsibilities describe a Paramedic’s scope of practice.
• A superior EMS system is always in a process of review and re-engineering through continuous quality improvement (CQI) and quality assurance (QA).
• Involvement in professional development provides the Paramedic with competence assurance, and allows the Paramedic to remain current with the state of the art as a life-long learner.
• Changes in EMS are now driven by research, and the process has become more reliable and valid to the Paramedic practice.
• In an effort to reduce injury and illness, the Paramedic has become a health educator.
• The professional Paramedic is also a patient advocate.
• As a physician extender, the Paramedic is authorized to practice under the license granted to the physician.
• The Paramedic serves as a model of ethical behavior.
• A Paramedic leader is a strong communicator and has the ability to organize a team’s efforts to deliver appropriate intervention in a timely manner.
• The Paramedic, as a follower, is willing to follow a leader’s direction and support the mission.
