How Paramedics Work

Today's paramedicine field owes much to the efforts of Ron Stewart.

"I'm not dead yet!" Ron Stewart yelled to the people standing around his hospital bedside — but they couldn't hear him. He'd suffered a traumatic brain injury after accidentally driving his car off a cliff in Nova Scotia during a snowstorm. The people at his bedside were lamenting the loss of such a promising physician. In 1971 Stewart was a 28-year-old doctor who'd been racing to the scene of an emergency when he lost control of his car. "I'm alive!" Stewart's mind shouted again, but he still couldn't be heard.

The frontal temporal contusion he'd sustained could've left him dead or mentally disabled, but instead he slowly made an unlikely recovery — and that formative experience as a patient helped shape his extraordinary career. A year later, Stewart left Nova Scotia for California where he became resident in emergency medicine at Los Angeles County Hospital. There, not only did he treat the likes of a chained-up Charles Manson when the infamous killer was brought from prison with fight wounds, he also trained as many as 2,000 firefighters in paramedicine and served as a consultant to the influential TV show "Emergency!" [source: Meek]


Paramedicine as we know it was in its infancy back in the 1970s, and the young doctor from Cape Breton played an important role in its development. In fact, Stewart wrote the first paramedic training manual in 1974 [source: Health Services L.A. County]. From L.A., he moved to Pennsylvania where he became the founding head of the emergency medicine department at the University of Pittsburgh Medical Center. Not one to relax in the ivory tower, he continued to practice his profession, even going so far as to amputate a trapped construction worker's leg while swaying in high winds at the top of a 130-foot (40-meter) fire ladder.

After serving on President Bill Clinton's health advisory committee as an expert in trauma medicine, Stewart returned to Nova Scotia in 1993 to enter politics. There, while campaigning in his old Cape Breton neighborhood, he happened upon a potential constituent experiencing a heart attack. Starting cardiac massage, Stewart got the man stabilized and in the hospital before asking for his vote. Once elected he became the minister of health for the province, and the highlight of his political career was the establishment of a first-rate emergency medical system [source: Meek]. That system continues to innovate, pioneering new modes of paramedicine that are influencing health care across the continent.


Paramedicine Past

Ambulances might be loud, but at least they're not pulled by horses anymore like this early U.S. Army ambulance.

Paramedicine has been forged by war. In the 11th century, the Crusades gave birth to the Knights Hospitaller of the Order of Saint John of Jerusalem, a religious organization that developed some of the earliest known emergency medical practices for treating those wounded during the conflict's bloody battles. Among other innovations, the Knights Hospitaller invented the litter, a length of canvas suspended between two poles for transporting injured soldiers from the field of combat.

The Spanish improved on this concept in the late 15th century during the period of the Inquisition by setting up field hospitals known as "ambulancias," from which we derive the modern word "ambulance." But it wasn't until the Napoleonic wars in the early 19th century that the Grand Army's chief surgeon, Dominique Jean Larrey, realized he could improve outcomes for the wounded if he didn't wait until after the battle to treat them. He created horse-drawn "ambulances volantes," or "flying ambulances," to collect injured soldiers from the field even as the conflict raged. This concept soon made its way into civilian life when, in the 1830s, ambulance services formed in London to transport cholera victims to hospitals [source: Winston].


But, incredibly, it took an additional 130 years for the idea of staffing ambulances with trained medical personnel to gain ground. In 1967 Dr. J. Frank Pantridge of Belfast, Northern Ireland, published a landmark study of his successful use of a mobile coronary care unit staffed with a physician, nurse and ambulance attendant.

Change was in the air — just a year earlier in the U.S. the National Academy of Sciences published a report titled, "Accidental Death and Disability: The Neglected Disease of Modern Society." The report sounded the alarm, pointing out that car accidents killed more Americans in 1965 alone than were lost during the entire Korean War. One major reason for this was the dearth of proper emergency care.

Ambulances were often hearses staffed by morticians with no medical training. And when patients died, as they often did, they would leave the hospital in the same hearse in which they'd arrived. It was time, the Academy said, to create a standardized, nationwide system of emergency medical care. The Emergency Medical Systems Act was signed into law in 1973, and 1977 saw the publication of the first national standard curriculum for EMT-Paramedics. The revolution had begun [source: Winston].


Paramedics Today

CPR classes are a basic -- but essential -- part of any paramedic's training.
Mihajlo Maricic/iStock/Thinkstock

When people in uniforms jump from an ambulance to respond to a crisis, are they all paramedics? Probably not. There are various levels of certification available for people trained in prehospital care. At the entry level, there are emergency medical technicians (EMTs). They've usually completed between 120 and 150 hours of coursework, during which they're trained in a variety of lifesaving procedures including CPR, administering oxygen and dealing with allergic reactions. One thing they're not allowed to do is break the skin (so no needles) [source: UCLA].

By contrast, paramedics usually go to school for 1,200 to 1,800 hours [source: UCLA]. They can start IVs, manage airways, deal with heart attacks, and undertake advanced resuscitation and support. But to be eligible to become a paramedic, you have to have been a working EMT for at least six months prior.


The UCLA Center for Prehospital Care, which initiated emergency medical training back in 1970 and is home to the country's first nationally accredited paramedic program, charges $10,000 for basic tuition [source: UCLA]. Then there are fees for books, scrubs, uniforms, the national registry exam, state and local accreditation and licensing, and more. However, once you're done, you've got a good shot at employment. UCLA, for example, boasts that 95 percent of its graduates are working just six months after graduation [source: UCLA].

As for what you can earn, it all depends where you end up working. Strangely, the U.S. Bureau of Labor Statistics lumps EMTs and paramedics together in the data, giving a mean annual wage of $31,270 (2015 figures). Those in the top 10 percent of this broad category earned $54,710. Because the training programs for paramedics are 10 times as long as those for EMTs, we can only assume they're bringing in the higher income. But as with any job, salary depends on location. The state of Washington seems to really appreciate its paramedics — recent job postings there offer annual salaries as high as $71,790 [source: U.S. News & World Report].



Ron Stewart not only helped create the paramedicine field as we know it today, but he also consulted on the 1970s show "Emergency!"

As mentioned in the intro, Ron Stewart served as a consultant to the TV show "Emergency!" That series, which ran from 1972 to 1977, was much more than an entertaining drama about emergency medicine; it was a highly influential pop cultural phenomenon that had an important impact on the burgeoning field of paramedicine. In fact, scholars have argued that it helped create the cultural conditions necessary for the nationwide establishment of a paramedical system.

The show followed the exploits of John Gage and Roy DeSoto, two firefighters who had received special training as paramedics. Together, they were Squad 51, operating out of Station 51 in Los Angeles. The link with firefighting was, and still is, true to life: Today, many firefighting crews include a paramedic team. The show adhered to reality in other ways too. Shot in quasi-documentary style, its cast included many real-life personalities who played themselves, including the dispatcher and several firefighters.


The show's pilot episode revolves around the Wedworth-Townsend Paramedic Act, a piece of California state legislation designed to authorize paramedics to perform medical procedures in the field. Until Gov. Ronald Reagan signed the act into law on July 14, 1970, only doctors and nurses were permitted to treat patients using medically invasive procedures like defibrillation or IVs. The doctor who trains Gage and DeSoto is opposed to the idea that "hose jockeys" should become authorized medical personnel, but when they save lives, he changes his mind.

When "Emergency!" premiered in 1972, there were no more than a dozen paramedic units across North America. Ten years later, more than 50 percent of Americans lived within 10 minutes of emergency medical aid. While "Emergency!" was only one of many forces behind this massive change in access to paramedicine, the show has been credited with introducing a mass audience to the idea of prehospital care. By some accounts, good Samaritans may have saved lives using procedures they'd seen on "Emergency!" They may also have done some damage. This happened enough that the show devoted a portion of an episode to dissuade untrained civilians from performing potentially dangerous interventions [source: Yokely].


The Future of Paramedicine

Many paramedics and other health professionals recognize the importance of preventive care and community outreach, but budget issues get in the way of expanding these efforts.

Back when Ron Stewart was starting out as a young doctor he worked with a public health nurse in the most remote corner of the already remote island of Cape Breton. Nurse Isabel MacDonald knew everybody in the region, and thanks to her trusted relationship with the community members, Stewart realized that she was preventing potential illnesses at a rate far greater than he could ever cure them [source: Meek].

This early example stayed with him for the rest of his career, long after he had made a name for himself in the U.S. and returned to Nova Scotia. As the Minister of Health, not only did he standardize emergency services in the province, he pioneered an innovative form of paramedicine [source: District of Muskoka].


Inhabitants of the remote islands of Long and Brier off the southwest coast of Nova Scotia were having trouble accessing medical care. Stewart helped develop a pilot project in which paramedics stationed on the islands would not only react to emergencies, but they would also go out into the community and do what they could to prevent them. This might involve answering health-related questions over a cup of tea, administering medications or recommending the best shoes to wear to avoid falls. The results were dramatic: Visits to the hospital on the mainland dropped by 24 percent to 28 percent between 2001 and 2006 [source: Accreditation Canada].

The model has been so successful that it has spread around the world from Scotland to Australia. In San Francisco, for instance, a program that sent paramedics out among the homeless population helped reduce 911 calls by 75 percent over the course of a year and a half, saving roughly $12 million. In Colorado, a community paramedic leads fitness training courses at a senior home and makes home visits to ensure elderly community members are taking their prescriptions correctly [source: Johnson].

Programs like these are promising, but unless funds are specifically set aside for a project, paramedics and other caregivers will encounter a major stumbling block. Federal rules say that prehospital caregivers get paid only when they load somebody into their ambulances and move them to or from a health care facility [source: Johnson]. These rules may change in time.

In 2005, Ron Stewart hosted 50 delegates from the U.S., Canada, Scotland and Australia at a conference called the International Roundtable on Community Paramedicine (IRCP). Since then, the IRCP has been going strong with meetings held every year around the world [source: IRCP].


Lots More Information

Author's Note: How Paramedics Work

A friend of mine is a paramedic in a large North American city, and some of the tales she has to tell of her day-to-day work are very, very dark. But some are more lighthearted. One of my favorites is her story of walking up six flights of stairs to an apartment where a man complaining of a sore back asked her to heat his dinner in the microwave. This was at the end of a long day in the middle of an August heat wave. My friend was tired, cranky, sweating and (a small detail) six months' pregnant at the time. She gave him a thorough tongue-lashing for wasting her time and the city's money. That's a speech I'd like to have heard — never cross a pregnant paramedic.

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More Great Links

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