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Star of Life

In most circumstances in the United States, a paramedic is the most advanced medical professional who typically responds to and treats medical emergencies and trauma in the pre-hospital setting. Paramedics normally provide assessment of illness and injuries, including the gathering of medical history information, and provide potentially life-sustaining medical treatment to the victim, both on scene and during transportation to a hospital emergency department. The training, supervision and licensing, and skill sets for this group are determined at the State level, and vary widely across the United States. Paramedics may be found in a variety of settings, including traditional emergency medical services (EMS), other emergency services, such as both fire departments and police, inside of hospitals and in industrial settings. The position normally involves paid employment, although in increasingly rare situations, one may find paramedics working as unpaid volunteers.

Contents

History

Prior to 1970, ambulances were staffed with advanced first-aid level responders who were frequently referred to as "ambulance drivers." There was little regulation or standardized training for those staffing these early emergency response vehicles. Around 1966 in a published report entitled "Accidental Death and Disability: The Neglected Disease of Modern Society",[1] (known in EMS trade as the White Paper) medical researchers began to reveal, to their astonishment, that soldiers who were seriously wounded on the battlefields of Vietnam had a better survival rate than those individuals who were seriously injured in motor vehicle accidents on California freeways. Early research attributed these differences in outcome to a number of factors, including comprehensive trauma care, rapid transport to designated trauma facilities, and a new type of medical corpsman; one who was trained to perform certain critical advanced medical procedures such as fluid replacement and airway management, which allowed the victim to survive the journey to definitive care.

As a result of this publication, a series of grand experiments began in the United States. Pittsburgh's Freedom House paramedics are credited as the first EMT trainees in America. Pittsburgh's Peter Safar is referred to as the father of CPR.[2] In 1967, he began training unemployed African-American men in what later became Freedom House Ambulance Service,[3] the first paramedic squadron in the United States.[4][5] Almost simultaneously, and completely independent from one another, experimental programs began in three U.S. centers; Miami, Florida, Seattle, Washington, and Los Angeles, California. Each was aimed at determining the effectiveness of using firefighters to perform many of these same advanced medical skills in the pre-hospital setting in the civilian world. Many in the senior administration of the fire departments were initially quite opposed to this concept of 'firemen giving needles', and actively resisted and attempted to cancel pilot programs more than once. In Seattle, the Medic One program at Harborview Medical Center and the University of Washington Medical Center, started by Leonard Cobb, M.D., began training firefighters in CPR in 1970.[6] Dr. Eugene Nagel[7] trained city of Miami firefighters as the first U.S. paramedics to use invasive techniques and portable defibrillators with telemetry in 1967. In Los Angeles, a pilot paramedic program, involving firefighters from only two county fire department rescue squads initially, began under the direction of Ronald Stewart, M.D.[8]

Elsewhere, the novel approach to pre-hospital care was also evolving. Portland's Leonard Rose, M.D., in cooperation with Buck Ambulance Service, instituted a cardiac training program and began training other paramedics. Baltimore's R. Adams Cowley,[9] the father of trauma medicine, devised the concept of integrated emergency care, designing the first civilian Medevac helicopter program and campaigning for a statewide EMS system. Other communities that were early participants in the development of paramedicine included Jacksonville, Florida, Pittsburgh, Pennsylvania (in an expanded program), and Seattle, Washington (in an expanded program). In 1972 the first civilian emergency medical helicopter transport service, Flight for Life opened in Denver, Colorado.[10] Emergency medical helicopters were soon put into service elsewhere in the United States. It is now routine to have paramedic and nurse-staffed EMS helicopters in most major metropolitan areas. The vast majority of these aeromedical services are utilized for critical care air transport (inter-hospital) in addition to emergency medical services (pre-hospital).

In a curious example of 'life imitating art' a television producer, working for producer Jack Webb,[11] of Dragnet (series) and Adam-12 fame, happened to be in Los Angeles' UCLA Harbor Medical Center, doing background research for a proposed new TV show about doctors, when he happened to encounter these 'firemen who spoke like doctors and worked with them'. This novel idea would eventually evolve into the Emergency! television series, which ran from 1972-1977, portraying the exploits of a new group called 'paramedics'. The show captured the imagination of emergency services personnel, the medical community, and the general public. When the show first aired in 1972, there were exactly 6 full-fledged paramedic units operating in 3 pilot programs (Miami, Los Angeles, Seattle) in the whole of the United States. No one had ever heard the term 'paramedic'; indeed, it is reported that one of the show's actors was initially concerned that the 'para' part of the term might involve jumping out of airplanes! By the time the program ended production in 1977, there were paramedics operating in every state. The show's technical advisor was a pioneer of paramedicine, James O. Page,[12] then a Battalion Chief responsible for the Los Angeles County Fire Department 'paramedic' program, but who would go on to help establish other paramedic programs in the U.S., and to become the founding publisher of the Journal of Emergency Medical Services.[13]

Throughout the 1970s and 80s, the field continued to evolve, although in large measure, on a local level. In the broader scheme of things the term 'ambulance service' was replaced by 'emergency medical service' in order to reflect the change from a transportation system to a system which provided actual medical care. The training, knowledge base, and skill sets of both paramedics and emergency medical technicians (both competed for the job title, and 'EMT-Paramedic' was a common compromise) were typically determined by what local medical directors were comfortable with, what it was felt that the community needed, and what could actually be afforded. There were also tremendous local differences 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 ultimately even to universities. During the evolution of paramedicine, a great deal of both curriculum and skill set was in a state of constant flux. Permissible skills evolved in many cases at the local level, and were based upon the preferences of physician advisers and medical directors. Treatments would go in and out of fashion, and sometimes, back in again. The use of certain drugs, Bretyllium for example, illustrate this. In some respects, the development seemed almost faddish. Technologies also evolved and changed, and as medical equipment manufacturers quickly learned, the pre-hospital environment was not the same as the hospital environment; equipment standards which worked fine in hospitals could not cope well with the less controlled pre-hospital environment.

Physicians began to take more interest in paramedics from a research perspective as well. By about 1990, most of the 'trendiness' in pre-hospital emergency care had begun to disappear, and was replaced by outcome-based research and evidence-based medicine;[14] the gold standard for the rest of medicine. This research began to drive the evolution of the practice of both paramedics and the emergency physicians who oversaw their work; changes to procedures and protocols began to occur only after significant outcome-based research demonstrated their need. Paramedics became increasingly accountable for their errors as well, and these too led to changes in procedure.[15] Such changes affected everything from simple procedures, such as CPR, to changes in drug protocols and other advanced procedures.[16] As the profession of paramedic grew, some of its members actually went on to become not just research participants, but researchers in their own right, with their own projects and journal publications.

Education

The education and skills required of paramedics vary by state. The NHTSA designs and specifies a National Standard Curriculum[17] for EMT training. Most paramedic education and certifying programs require that a student is at a minimum educated and trained to the National Standard Curriculum for a particular skill level.[18] The National Registry of Emergency Medical Technicians (NREMT) is a private, central certifying entity whose primary purpose is to maintain a national standard. NREMT also provides certification information for paramedics who relocate to another state.[19]

Paramedic education programs can be as short as 8 months or as long as 4 years. An Associate's degree program is 2 years, often administered through a community college. Degree programs are an option, with two year Associate's degree programs being most common, although four year Bachelor's degree programs exist. The institutions offering such training vary greatly across the country in terms of programs and requirements, and each must be examined by the prospective student in terms of both content and requirements where the prospective paramedic hopes to practice.[20] Regardless of education, all students must meet the same state requirements to take the certification exams, including the National Registry exams. In addition, most locales require that paramedics attend ongoing refresher courses to maintain their license or certification. In addition to state and national registry certifications, most paramedics are required to be certified in Pediatric Advanced Life Support, Pediatric Prehospital care or Pediatric Emergencies for the Prehospital Provider; Prehospital Trauma Life Support; International Trauma Life Support; and Advanced Cardiac Life Support. These additional requirements have education and certification from organizations such as the American Heart Association.

Credentialling and oversight

In the U.S., the community college training model remains the most common, although university-based paramedic education models continue to evolve. These variations in both educational approaches and standards led to tremendous differences from one location to another, and at its worst, created a situation in which a group of people with 120 hours of training, and another group (in another jurisdiction) with university degrees, were both calling themselves 'paramedics'. There were some efforts made to resolve these discrepancies. The National Association of Emergency Medical Technicians (NAEMT) along with National Registry of Emergency Medical Technicians (NREMT)[21] attempted to create a national standard by means of a common licensing examination, but to this day, this has never been universally accepted by U.S. States, and issues of licensing reciprocity for paramedics continue, although if a EMT obtains certification through NREMT (NREMT-P, NREMT-I, NREMT-B), this is accepted by 40 of the 50 states in the United States.[22] This confusion was further complicated by the introduction of complex systems of gradation of certification, reflecting levels of training and skill, but these too were, for the most part, purely local. To clarify, at least at a national level, the National Highway Traffic Safety Administration (NHTSA), which is the federal organization with authority to administer the EMS system, defines the various titles given to prehospital medical workers based on the level of care they provide. They are EMT-P (Paramedic), EMT-I (Intermediate), EMT-B (Basic), and First Responders. While providers at all levels are considered emergency medical technicians, the term "paramedic" is most properly used in the United States to refer only to those providers who are EMT-P's. Apart from this distinction, the only truly common trend that would evolve was the relatively universal acceptance of the term 'emergency medical technician' being used to denote a lower level of training and skill than a 'paramedic'.

Changes in procedures also included the manner in which the work of paramedics was overseen and managed. In the earliest days of the field, medical control and oversight was direct and immediate, with paramedics calling into a local hospital and receiving orders for every individual procedure or drug.[23] This still occurs in some jurisdictions, but is becoming very rare. As physicians began to build a bond of trust with paramedics, and experience in working with them, their confidence levels also rose. Increasingly, in many jurisdictions day to day operations moved from direct and immediate medical control to pre-written protocols or 'standing orders', with the paramedic typically only calling in for direction after the options in the standing orders had been exhausted.[24] Medical oversight became driven more by chart review or rounds, than by step by step control during each call.

Examples of skills performed by paramedics

Just as with the use of medications, the other medical skills and procedures permitted to paramedics varies broadly from one jurisdiction to another. It is not possible to provide a single set of skills or medications which would be universally representative of all paramedics in the United States. The lists which follow, while not universal, are fairly representative.

Skills by certification level

Although there is a great deal of variation in what paramedics are trained and permitted to do from region to region, some skills performed by paramedics include:

Treatment issue EMT-B and EMT-I skills [25] Some EMT-I and EMT-P skills[26] Advanced paramedic skills[27]
Airway management Manual and repositioning, Oro- and nasopharyngeal airway adjuncts, manual removal of obstructions, suctioning, and in some states Advanced Airway Management (combitube and King airways) Endotracheal intubation (in some cases, naso as well), advanced airway management, ETT, LMA, ETOA, and combitube, deep suctioning, use of Magill forceps Rapid sequence induction, surgical airways (including needle cricothyrotomy and others)
Breathing Initial assessment (rate, effort, symmetry, skin color), obstructed airway maneuver, passive oxygen administration by nasal canula, rebreathing and non-rebreathing mask, active oxygen administration by Bag-Valve-Mask (BVM) device. Pulse oximetry, active oxygen administration by endotracheal tube or other device using BVM Use of mechanical transport ventilators, active oxygen administration by surgical airway, decompression of chest cavity using needle/valve device (needle thoracotomy)
Circulation Assessment of pulse (rate, rhythm, volume), blood pressure and capillary refill, patient positioning to enhance circulation, recognition and control of hemorrhage of all types using direct and indirect pressure and tourniquets Ability to interpret assessment findings in terms of levels of perfusion, intravenous fluid replacement, vasoconstricting drugs intravenous plasma volume expanders, blood transfusion, intraosseous (IO) cannulation (placement of needle into marrow space of a large bone), central venous access (central venous catheter by way of external jugular or subclavian)
Cardiac arrest Cardiopulmonary resuscitation, airway management, manual ventilation with BVM, automatic external defibrillator Dynamic resuscitation including intubation, drug administration (includes anti-arrhythmics), ECG interpretation (may be limited to Lead II) Semi-automatic or manual defibrillator Expanded drug therapy options, ECG interpretation (12 Lead), manual defibrillator, synchronized mechanical or chemical cardioversion, external pacing of the heart
Cardiac Monitoring Cardiac monitoring and interpretation of ECGs 12-lead ECG monitoring and interpretation 18-lead ECG monitoring and interpretation
Drug administration Limited oral, limited aerosol, limited injection (usually IM) Intramuscular, subcutaneous, intraosseous, intravenous injection (bolus), IV drip Per Endotracheal Tube (ETT), via retcal route (pr), per infusion pump
Drug types permitted Low-risk/immediate requirements, such as aspirin (chest pain), nitroglycerin (chest pain), oral glucose (diabetes), glucagon (diabetes), epinephrine (Allergic Reaction), or ventolin (Asthma). Some jurisdictions also permit naloxone (Narcotic Overdose), nitrous oxide (for pain); there is considerable variation by jurisdiction. Considerable expansion of permitted drugs, but still typically limited to about 20, including analgesics (narcotic or otherwise) (for pain), antiarrhythmics (irregularities in heartbeat), major cardiac resuscitation drugs, bronchodilators (for breathing), vasoconstrictors (to improve circulation), sedatives Dramatically expanded (up to 60+) drug list. In some jurisdictions advanced levels of paramedics are permitted to administer any drug, as long as they are familiar with it. In some jurisdictions certain types of advanced paramedics have limited authority to prescribe medications.
Patient assessment Basic physical assessment, 'vital' signs, history of general and current condition More detailed physical assessment and history, auscultation, interpretation of assessment findings, ECG interpretation, glucometry, capnography, pulse oximetry Interpretation of lab results, interpretation of chest x-rays, interpretation of cranial CT scan, limited diagnosis (e.g. rule out fracture using Ottawa Ankle Rules)
Wound management Assessment, control of bleeding, application of pressure dressings and other types of dressings Wound cleansing, wound closure with Steri-strips, suturing

Skills common to all EMTs and Paramedics

  • Spinal injury management, including immobilization and safe transport.
  • Fracture management, including assessment, splinting, traction splints where appropriate.
  • Obstetrics, assessment, assisting with uncomplicated childbirth, recognition of and procedures for obstetrical emergencies, such as breech presentation, cord presentation, placental abruption.
  • Management of burns, including classification, estimate of surface area, recognition of more serious burns, treatment.
  • Assessment and evaluation of general incident scene safety.
  • Effective verbal and written reporting skills (Charting).
  • Routine medical equipment maintenance procedures.
  • Routine radio operating procedures.
  • Triage of patients in a mass casualty incident.
  • Emergency vehicle operation.

Medications administered

Paramedics in most jurisdictions administer a variety of emergency medications; the individual medications vary widely, based on physician medical director preference, local standard of care, and law. These drugs may include Adenocard (Adenosine),[28] which will slow the heart for a short period of time, and Atropine, which will speed a heartbeat that is too slow. The list may include sympathomimetics like dopamine for severe hypotension (low blood pressure) and cardiogenic shock. Diabetics often benefit from the fact that paramedics are able to give D50W (Dextrose 50%) to treat hypoglycemia (low blood sugar). They can treat crisis and anxiety conditions. Some advanced paramedics may also be permitted to perform rapid sequence induction; a rapid way of obtaining an advanced airway with the use of paralytics and sedatives, using such medications as Versed, Ativan, or Etomidate, and paralytics such as succinylcholine, rocuronium, or vecuronium.[29] Paramedics in some jurisdictions may also be permitted to sedate combative patients using antipsychotics like Haldol or Geodon.[30] The use of medications for treating respiratory conditions such as, albuterol, atrovent, and methylprednisolone is common. Paramedics may also be permitted to administer medications such as those which relieve pain or decrease nausea and vomiting. Nitroglycerin, baby aspirin, and morphine sulfate may be administered for chest pain. Paramedics may also use other medications and antiarrhythmics like amiodarone to treat cardiac arrhythmias such as ventricular tachycardia and ventricular fibrillation not responding to defibrillation.[31] Paramedics also treat for severe pain, i.e. burns or fractures, with narcotics like morphine sulfate, pethidine, fentanyl and in some jurisdictions, ketorolac. This list is not representative of all jurisdictions, and EMS jurisdictions may vary greatly in what is permitted. Some jurisdictions may not permit administration of certain classes of drugs, or may use drugs other than the ones listed for the same purposes. For an accurate description of permitted drugs or procedures in a given location, it is necessary to contact that jurisdiction directly.

Employment

Paramedics are employed by various public and private emergency service providers. These include private ambulance services, fire departments, public safety or police departments, hospitals, law enforcement agencies, the military, and municipal EMS agencies in addition to and independent from police or fire departments, also known as a 'third service'. Paramedics may respond to medical incidents in an ambulance, rescue vehicle, helicopter, fixed-wing aircraft, motorcycle, or fire suppression apparatus.

Example of an official shoulder emblem worn by paramedics to identify their advanced level of care.

Paramedics may also be employed in medical fields that do not involve transportation of patients. Such positions include offshore drilling platforms, phlebotomy, blood banks, research labs, educational fields, law enforcement and hospitals.[32]

Aside from their traditional roles, paramedics may also participate in one of many specialty arenas:

  • Critical care transporters move patients by ground ambulance or aircraft between medical treatment facilies. This may be done to allow a patient to receive a higher level of care in a more specialized facility. Registered Nurses with training in critical care medicine may work side-by-side with paramedics in these settings. Paramedics participating in this role generally also provide care not traditionally administered by Paramedics who respond to 911 calls. Examples of this are blood transfusions, intra-aortic balloon pumps, and mechanical ventilators.[33]
  • Tactical paramedics work on law enforcement teams (SWAT). These medics, usually from the EMS agency in the area, are commissioned and trained to be tactical operators in law enforcement, in addition to paramedic duties. Advanced medical personnel perform dual roles as operator and medic on the teams. Such an officer is immediately available to deliver advanced emergency care to other injured officers, suspects, innocent victims and bystanders.[34]
  • In-Hospital paramedics are increasingly employed in hospital emergency departments and intensive care units due to the nursing shortage. In emergent situations, paramedics are generally accustomed to practicing with greater latitude and autonomy than registered nurses due to their specialized training, which emphasizes discretionary decisions and treatment without mandatory physician consultation.[35]

See also

References

  1. ^ National Research Council; Committee on Trauma and Committee on Shock; Division of Medical Sciences; National Academy of Sciences (2000). Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, D.C: National Academies Press. ISBN 0-309-07532-7.  
  2. ^ Grenvik A, Kochanek PM (February 2004). "The incredible career of Peter J. Safar, MD: the Michelangelo of acute medicine". Critical care medicine 32 (2 Suppl): S3–7. PMID 15043225. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0090-3493&volume=32&issue=2&spage=S3.  
  3. ^ "Freedom House". http://www.freedomhousedoc.com/. Retrieved 2008-11-07.  
  4. ^ "Send Freedom House!". http://www.umc.pitt.edu/media/pcc040223/BHMS_freedom_house.html. Retrieved 2007-06-26.  
  5. ^ "Pitt Magazine". Spring, 2007. pp. 6.  
  6. ^ "Cobb Honored as one of Resuscitation Greats". http://depts.washington.edu/mednews/vol6/no33/cobb.html. Retrieved 2008-11-07.  
  7. ^ "Dr Eugene L. Nagel". http://www.zoominfo.com/people/Nagel_Eugene_3006219.aspx. Retrieved 2007-08-06.  
  8. ^ "Dalhousie University Faculty of Medicine website". http://communications.medicine.dal.ca/newsroom/stewart.htm. Retrieved 2008-11-07.  
  9. ^ "Tribute to R. Adams Cowley". http://www.umm.edu/shocktrauma/history.htm. Retrieved 2008-11-07.  
  10. ^ "Flight for Life Colorado website". http://www.flightforlifecolorado.org/index.php?s=5. Retrieved 2008-11-07.  
  11. ^ "Jack Webb (Museum of Broadcast Communications website)". http://www.museum.tv/archives/etv/W/htmlW/webbjack/webbjack.htm. Retrieved 2008-11-07.  
  12. ^ "Fire and EMS Service Icon James O. Page Passes Away". http://cms.firehouse.com/web/online/Emergency-Medical-Services/Fire-and-EMS-Service-Icon-James-O-Page-Passes-Away/17$34818. Retrieved 2008-11-07.  
  13. ^ "Journal of Emergency Medical Services website". http://www.jems.com/news_and_articles/articles/All_JEMS_Articles.html. Retrieved 2008-11-07.  
  14. ^ Sackett, David L; Rosenberg, William M C; Gray, J A Muir; Haynes, R Brian; Richardson, W Scott (1996-01-13). "Evidence based medicine: what it is and what it isn't". British Medical Journal (312): pp. 71–72. http://www.bmj.com/cgi/content/full/312/7023/71. Retrieved 2008-06-14.  
  15. ^ Meisel, Zachary (2005-11-08). "Ding-a-Ling-a-Ling". Slate. http://www.slate.com/id/2129684/. Retrieved 2008-06-14.  
  16. ^ Burton, John H (June 2006). "Out-of-Hospital Endotracheal Intubation: Half Empty or Half Full?". Annals of Emergency Medicine 47 (6): pp. 542–544. doi:10.1016/j.annemergmed.2006.01.023. http://linkinghub.elsevier.com/retrieve/pii/S0196064406000886. Retrieved 2008-06-14.  
  17. ^ "National Standard Curriculum". http://www.nhtsa.dot.gov/portal/site/nhtsa/template.MAXIMIZE/menuitem.2a0771e91315babbbf30811060008a0c/?javax.portlet.tpst=4670b93a0b088a006bc1d6b760008a0c_ws_MX&javax.portlet.prp_4670b93a0b088a006bc1d6b760008a0c_viewID=detail_view&javax.portlet.begCacheTok=com.vignette.cachetoken&javax.portlet.endCacheTok=com.vignette.cachetoken&itemID=1822abcc80c81010VgnVCM1000002c567798RCRD&overrideViewName=Article. Retrieved 2007-08-08.  
  18. ^ "National Standard Curriculum". http://www.nhtsa.dot.gov/portal/site/nhtsa/template.MAXIMIZE/menuitem.2a0771e91315babbbf30811060008a0c/?javax.portlet.tpst=4670b93a0b088a006bc1d6b760008a0c_ws_MX&javax.portlet.prp_4670b93a0b088a006bc1d6b760008a0c_viewID=detail_view&javax.portlet.begCacheTok=token&javax.portlet.endCacheTok=token&itemID=1822abcc80c81010VgnVCM1000002c567798RCRD&overrideViewName=Article. Retrieved 2008-11-07.  
  19. ^ "State Office Information". http://www.nremt.org/EMTServices/emt_cand_state_offices.asp. Retrieved 2007-08-08.  
  20. ^ "Nationwide Directory of Paramedic Schools". http://www.medicschools.com. Retrieved 2008-11-07.  
  21. ^ "NREMT website". http://www.nremt.org/about/nremt_news.asp. Retrieved 2008-11-07.  
  22. ^ "Reciprocity Information (NREMT website)". http://www.nremt.org/emtservices/emt_cand_state_offices.asp.  
  23. ^ Kuehl, Alexander (2002). Prehospital systems and medical oversight. Dubugue, Iowa: Kendall/Hunt Pub. ISBN 0-7872-7071-7.  
  24. ^ Victoria L. Fedor; Jacob L. Hafter (2003). EMS and the Law. Sudbury, Mass: Jones & Bartlett Publishers. ISBN 0-7637-2068-2.  
  25. ^ "EMT-Basic Practical Evaluation Guidelines and Skill Sheets (State of Washington)". http://www.doh.wa.gov/hsqa/emstrauma/download/emtapndxh.pdf. Retrieved 2008-11-10.  
  26. ^ "Emergency Medical Technician-Paramedic (California Code of Regulations)". http://www.emsa.ca.gov/laws/files/ch4_emtp%20.pdf. Retrieved 2008-11-10.  
  27. ^ "Tennessee Critical Care Paramedic Standardized Modules and Objectives". http://health.state.tn.us/Downloads/ems_CriticalCareStandardizedModules.pdf. Retrieved 2008-11-10.  
  28. ^ "North Carolina EMS Drug List". http://www.nccep.org/content/ems/standards/druglist/DRUGLIST2005.pdf. Retrieved 2008-11-10.  
  29. ^ "EMS Protocols, Pitt County (NC)". http://www.greenvillenc.gov/uploadedFiles/Departments/Fire_Department/Information/EMS/2006%20EMS%20PROTOCOL%20rev3%202007%20(2).pdf. Retrieved 2008-11-10.  
  30. ^ "Wisconsin Paramedic Medication List". http://dhs.wisconsin.gov/ems/License_certification/Paramedic_SCT_Meds.pdf. Retrieved 2008-11-10.  
  31. ^ "Paramedic Protocols, Denver (Co)". http://www.dgprotocols.com/amiodarone.html. Retrieved 2008-11-10.  
  32. ^ "Emergency Medical Technicians and Paramedics in California". http://www.futurehealth.ucsf.edu/pdf_files/EMT14pfdoc.pdf. Retrieved 2008-11-10.  
  33. ^ "What is a Pediatric/Neonatal Critical Care Transport Team?". http://www.aap.org/sections/pem/PediatricTransportTeam_final.pdf. Retrieved 2008-11-10.  
  34. ^ "Tactical Paramedic Operations". http://www.srpmic-nsn.gov/community/fire/Welcome/Salt%20River%20Fire%20Dept%20SOGs/209.03%20-%20TACTICAL%20PARAMEDIC%20OPERATIONS.pdf. Retrieved 2008=11-10.  
  35. ^ "Comparison of Paramedics and Emergency Nurses". http://www.jems.com/news_and_articles/articles/The_View_from_the_Other_Side.html. Retrieved 2008-02-03.  

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