Types of Occupational Hazards

Environmental and Operational Hazards

Paramedics are confronted with many challenges exhibited in the form of environmental and operational risks, primarily during transportation. These transportation-related hazards should be considered and addressed in prehospital care.^[18] Slips, trips, and falls; motor vehicle incidents; and violence or assaults have huge impact on paramedics' occupational hazards, resulting to thousands of paramedics impacted annually.^[19][11] Vehicle safety features need to be known by paramedics, and so must undergo exhaustive emergency driving training, which looks into curbing the provisions that are the peril of transportation. Paramedics are frequently assaulted by patients or bystanders affecting around 2,000 EMS workers annually, which further hammers the need for training on de-escalation.^[11][13] NIOSH and the Department of Homeland Security have conducted ambulance crash testing, resulting in the development of 10 test methods published by the Society of Automotive Engineers (SAE) to reduce and eliminate crash-related injuries to EMS workers.^[11] Through effective training, the threat cases are more likely to be mitigated, and the paramedics will have a better chance to provide services as required.

Protective Measures and Equipment

One way of ensuring paramedics work at optimal efficiency is to provide them with protective equipment and gear to mitigate the possible risks when executing their duties. PPE keeps paramedics’ occupational risks low.^[20] Examples of PPEs include gloves, masks, and gown or specific clothing; they protect workers from physical, biological, and chemical hazards. The different types of PPE include respiratory, eye, face, and hand protection. Under respiratory protection, paramedics can use N95 masks to filter airborne contaminants. Chemical splashes are also a common hazard faced by paramedics, where safety gaggles can be used for eye protection. Underhand protection, paramedics can employ gloves mainly to curb burns. One of the principles of PPE is that choices should be guided by specific risks associated with various emergencies, which warrant different PPE requirements.^[21]

Mental Health and Stress Management

Paramedic are involved in challenging professions and can be subject to different kinds of psychological stress, for instance, post-traumatic stress disorder, depression, or severe burnout. The psychological aspect is intertwined with the nature of the paramedics' work. Exposure to traumatic events such as accidents, medical emergencies, and violence are some of the factors undermining the psychological health of paramedics.^[15] Mental health issues, including depression, anxiety, and substance abuse, are some of the mental health issues paramedics are likely to get exposed to due to their nature of work as compared to the general population.^[22] Stable support systems that may include peer counselling and the availability of mental health resources become essential in building the resilience of paramedic professionals. Peer counselling programs appear to be an effective stress management strategy for paramedics.^[17] Taking part in open discussions with other peers who understand what the employee is going through determines the necessary supportive grounds that facilitate managing and processing feelings related to this work.

Health Risks and Monitoring

The long-term health risks that need to be observed by the paramedics are Post Traumatic Stress Disorder (PTSD), cardiovascular diseases (CVDs), and cancer risk. There are a variety of challenges paramedics encounter, including PTSD, which should provide a compelling reason to implement preventive mental health measures within this profession.^[14] Moreover, there is an extra risk for CVDs because of the heaviness of emergency response operations. There is a need to emphasize cancer risk and the importance of constant exploration and individualized prevention patterns. Besides, there is the cumulative effect of fatigue, violence, and trauma on the health of paramedics. As a result, there is a need for systematic monitoring and preventive measures in health among paramedics.^[23] It is necessary to study long-term health risks for paramedics and apply a prophylactic approach to maintaining the health state of healthcare professionals.^[21]

Regulatory Guidelines and Recommendations

The regulatory guidelines are fundamental in eliminating occupational risk in paramedicine; authoritative bodies like the Occupational Safety and Health Administration (OSHA) and the World Health Organization (WHO) provide specific guidelines. For example, in United States, physical, chemical, and biological hazards are managed by operating under the guidelines and recommendations offered by NIOSH and OSHA, targeting the healthcare industry especially.^[24] These include properly using PPE, handling hazardous substances, and adequately managing workplace violence. Moreover, the WHO provides global views by laying international standards to protect the well-being of the staff involved in the healthcare provided, irrespective of whether it is an emergency or routine operation.^[25] Such regulatory bodies, as the ones promoting national and global safety standards, ensure that evidence-based approaches reinforce adherence to their occupational health being safeguarded.

Early history

Throughout the evolution of pre-hospitalization care, there has been an ongoing association with military conflict. One of the first indications of a formal process for managing injured people dates from the Imperial Legions of Rome, where aging Centurions, no longer able to fight, were given the task of organizing the removal of the wounded from the battlefield and providing some form of care. Such individuals, although not physicians, were probably among the world's earliest surgeons by default, being required to suture wounds and complete amputations. A similar situation existed in the Crusades, with the Knights Hospitaller of the Order of St. John of Jerusalem filling a similar function; this organisation continued, and evolved into what is now known throughout the Commonwealth of Nations as the St. John Ambulance and as the Order of Malta Ambulance Corps in the Republic of Ireland and various countries.

Early ambulance services

While civilian communities had organized ways to deal with prehospitalisation care and transportation of the sick and dying as far back as the bubonic plague in London between 1598 and 1665, such arrangements were typically ad hoc and temporary. In time, however, these arrangements began to formalize and become permanent. During the American Civil War, Jonathan Letterman devised a system of mobile field hospitals employing the first uses of the principles of triage. After returning home, some veterans began to attempt to apply what had they had seen on the battlefield to their own communities, and commenced the creation of volunteer life-saving squads and ambulance corps.

These early developments in formalized ambulance services were decided at local levels, and this led to services being provided by diverse operators such as the local hospital, police, fire brigade, or even funeral directors who often possessed the only local transport allowing a passenger to lie down. In most cases these ambulances were operated by drivers and attendants with little or no medical training, and it was some time before formal training began to appear in some units. An early example was the members of the Toronto Police Ambulance Service receiving a mandatory five days of training from St. John as early as 1889.^[26]

Prior to World War I motorized ambulances started to be developed, but once they proved their effectiveness on the battlefield during the war the concept spread rapidly to civilian systems. In terms of advanced skills, once again the military led the way. During World War II and the Korean War battlefield medics administered painkilling narcotics by injection in emergency situations, and pharmacists' mates on warships were permitted to do even more without the guidance of a physician. The Korean War also marked the first widespread use of helicopters to evacuate the wounded from forward positions to medical units, leading to the rise of the term "medevac". These innovations would not find their way into the civilian sphere for nearly twenty more years.

Prehospital emergency medical care

By the early 1960s experiments in improving medical care had begun in some civilian centres. One early experiment involved the provision of pre-hospital cardiac care by physicians in Belfast, Northern Ireland, in 1966.^[27] This was repeated in Toronto, Canada in 1968 using a single ambulance called Cardiac One, which was staffed by a regular ambulance crew, along with a hospital intern to perform the advanced procedures. While both of these experiments had certain levels of success, the technology had not yet reached a sufficiently advanced level to be fully effective; for example, the Toronto portable defibrillator and heart monitor was powered by lead-acid car batteries, and weighed around 45 kilograms (99 lb).

In 1966, a report called Accidental Death and Disability: The Neglected Disease of Modern Society—commonly known as The White Paper—was published in the United States. This paper presented data showing that soldiers who were seriously wounded on the battlefields during the Vietnam War had a better survival rate than people who were seriously injured in motor vehicle accidents on California's freeways.^[28] Key factors contributing to victim survival in transport to definitive care such as a hospital were identified as comprehensive trauma care, rapid transport to designated trauma facilities, and the presence of medical corpsmen who were trained to perform certain critical advanced medical procedures such as fluid replacement and airway management.

As a result of The White Paper, the US government moved to develop minimum standards for ambulance training, ambulance equipment and vehicle design. These new standards were incorporated into Federal Highway Safety legislation and the states were advised to either adopt these standards into state laws or risk a reduction in Federal highway safety funding. The "White Paper" also prompted the inception of a number of emergency medical service (EMS) pilot units across the US including paramedic programs. The success of these units led to a rapid transition to make them fully operational.

Founded in 1967, Freedom House Ambulance Service was the first civilian emergency medical service in the United States to be staffed by paramedics, most of whom were Black. New York City's Saint Vincent's Hospital developed the United States' first Mobile Coronary Care Unit (MCCU) under the medical direction of William Grace, MD, and based on Frank Pantridge's MCCU project in Belfast, Northern Ireland.^[when?] In 1967, Eugene Nagle, MD and Jim Hirschmann, MD helped pioneer the United States' first EKG telemetry transmission to a hospital and then in 1968, a functional paramedic program in conjunction with the City of Miami Fire Department. In 1969, the City of Columbus Fire Services joined with the Ohio State University Medical Center to develop the "HEARTMOBILE" paramedic program under the medical direction of James Warren, MD and Richard Lewis, MD. In 1969, the Haywood County (NC) Volunteer Rescue Squad developed a paramedic program (then called Mobile Intensive Care Technicians) under the medical direction of Ralph Feichter, MD. In 1969, the initial Los Angeles paramedic training program was instituted in conjunction with Harbor General Hospital, now Harbor–UCLA Medical Center, under the medical direction of J. Michael Criley, MD and James Lewis, MD. In 1969, the Seattle "Medic 1" paramedic program was developed in conjunction with the Harborview Medical Center under the medical direction of Leonard Cobb, MD. The Marietta (GA) initial paramedic project was instituted in the Fall of 1970 in conjunction with Kennestone Hospital and Metro Ambulance Service, Inc. under the medical direction of Luther Fortson, MD.^[29] The Los Angeles County and City established paramedic programs following the passage of The Wedsworth-Townsend Act in 1970. Other cities and states passed their own paramedic bills, leading to the formation of services across the US. Many other countries also followed suit, and paramedic units formed around the world.

In the military, however, the required telemetry and miniaturization technologies were more advanced, particularly due to initiatives such as the space program. It would take several more years before these technologies drifted through to civilian applications. In North America, physicians were judged to be too expensive to be used in the pre-hospital setting, although such initiatives were implemented, and sometimes still operate, in European countries and Latin America.

Public notability

While doing background research at Los Angeles' UCLA Harbor Medical Center for a proposed new show about doctors, television producer Robert A. Cinader, working for Jack Webb, happened to encounter "firemen who spoke like doctors and worked with them". This concept developed into the television series Emergency!, which ran from 1972 to 1977, portraying the exploits of this new profession called paramedics. The show gained popularity with emergency services personnel, the medical community, and the general public. When the show first aired in 1972, there were just six paramedic units operating in three pilot programs in the whole of the US, and the term paramedic was essentially unknown. By the time the program ended in 1977, there were paramedics operating in all fifty states. The show's technical advisor, James O. Page, was a pioneer of paramedicine and responsible for the UCLA paramedic program; he would go on to help establish paramedic programs throughout the US, and was the founding publisher of the Journal of Emergency Medical Services (JEMS). The JEMS magazine creation resulted from Page's previous purchase of the PARAMEDICS International magazine. Ron Stewart, the show's medical director, was instrumental in organizing emergency health services in southern California earlier in his career during the 1970s, in the paramedic program in Pittsburgh, and had a substantial role in the founding of the paramedic programs in Toronto and Nova Scotia, Canada.

Evolution and growth

Throughout the 1970s and 1980s, the paramedic field continued to evolve, with a shift in emphasis from patient transport to treatment both on scene and en route to hospitals. This led to some services changing their descriptions from "ambulance services" to "emergency medical services".

The training, knowledge-base, and skill sets of both paramedics and emergency medical technicians (EMTs) were typically determined by local medical directors based primarily on the perceived needs of the community along with affordability. There were also large differences between localities 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 up to university level education. This emphasis on increasing qualifications has followed the progression of other health professions such as nursing, which also progressed from on the job training to university level qualifications.

The variations in educational approaches and standards required for paramedics has led to large differences in the required qualifications between locations—both within individual countries and from country to country. Within the UK training is a three-year course equivalent to a bachelor's degree. Comparisons have been made between Paramedics and nurses; with nurses now requiring degree entry (BSc) the knowledge deficit is large between the two fields. This has led to many countries passing laws to protect the title of "paramedic" (or its local equivalent) from use by anyone except those qualified and experienced to a defined standard. This usually means that paramedics must be registered with the appropriate body in their country; for example all paramedics in the United Kingdom must by registered with the Health and Care Professions Council (HCPC) in order to call themselves a paramedic. In the United States, a similar system is operated by the National Registry of Emergency Medical Technicians (NREMT), although this is only accepted by forty of the fifty states.

As paramedicine has evolved, a great deal of both the curriculum and skill set has existed in a state of flux. Requirements often originated and evolved at the local level, and were based upon the preferences of physician advisers and medical directors. Recommended treatments would change regularly, often changing more like a fashion than a scientific discipline. Associated technologies also rapidly evolved and changed, with medical equipment manufacturers having to adapt equipment that worked inadequately outside of hospitals, to be able to cope with the less controlled pre-hospital environment.

Physicians began to take more interest in paramedics from a research perspective as well. By about 1990, the fluctuating trends began to diminish, being replaced by outcomes-based research. This research then drove further evolution of the practice of both paramedics and the emergency physicians who oversaw their work, with changes to procedures and protocols occurring only after significant research demonstrated their need and effectiveness (an example being ALS). Such changes affected everything from simple procedures such as CPR, to changes in drug protocols. As the profession grew, some paramedics went on to become not just research participants, but researchers in their own right, with their own projects and journal publications. In 2010, the American Board of Emergency Medicine created a medical subspecialty for physicians who work in emergency medical services.^[30]

Changes in procedures also included the manner in which the work of paramedics was overseen and managed. In the early days medical control and oversight was direct and immediate, with paramedics calling into a local hospital and receiving orders for every individual procedure or drug. While this still occurs in some jurisdictions, it has become increasingly rare. Day-to-day operations largely moved from direct and immediate medical control to pre-written protocols or standing orders, with the paramedic typically seeking advice after the options in the standing orders had been exhausted.

Common skills

While there are varying degrees of training and expectations around the world, a set of skills practiced by paramedics in the pre-hospital setting commonly includes:^[46]

• Advanced cardiac life support, or ACLS, including cardiopulmonary resuscitation, defibrillation, cardioversion, transcutaneous pacing, and administration of cardiac drugs
• Patient assessment, including acquisition of vital signs, physical exam, chest auscultation, history taking, electrocardiogram acquisition and interpretation, capnography, pulse oximetry, point-of-care ultrasound and basic blood chemistry interpretation (glucose, lactate)
• Airway management techniques including tracheal intubation, cricothyrotomy, rapid sequence induction, supraglottic airway insertion, manual repositioning, sterile suctioning, use of oropharyngeal and nasopharyngeal airway adjuncts, and manual removal of obstructions via direct laryngoscopy and use of magill forceps
• Thorocostomy and pericardiocentesis to relieve pneumothorax and pericardial tamponade
• Intravenous (IV) and intraosseous (IO) cannulation
• Oxygen administration and positive pressure ventilation via bag-valve-mask, CPAP device, or ventilator
• Fluid resuscitation
• Administration of emergency drugs/medications (see section below)
• Bleeding control and management of shock
• Spinal injury management, including immobilization and safe transport
• Fracture management, including assessment, splinting, and dislocation reduction
• Obstetrics, including assessment, childbirth, and recognition of and procedures for obstetrical emergencies such as breech presentation, cord presentation, and placental abruption
• Management of burns, including classification, estimate of surface area, recognition of more serious burns, and treatment
• Triage of patients in a mass casualty incident
• Surgical procedures such as field amputation, escharotomy, or thorocotomy^[47] (if trained and credentialed)

Emergency Pharmacology

Paramedics carry and administer a wide array of emergency medications. The specific medications they are permitted to administer vary widely, based on local standards of care and protocols. For an accurate description of permitted drugs or procedures in a given location, it is necessary to contact that jurisdiction directly. A representative list of medications may commonly include:

• Analgesic medications such as aspirin, ketorolac and paracetamol (acetaminophen), used to relieve pain or decrease nausea and vomiting
• Narcotics like morphine, pethidine, fentanyl, and methoxyflurane, used to treat severe pain.
• Beta and calcium channel blockers such as diltiazem, metoprolol and verapamil used to slow down excessively high heart rates or severe hypertension
• Parasympatholytic drug such as Atropine, also known as anticholinergic drugs, used to speed up slow bradycardic heart rates
• Sympathomimetics^[48] such as dopamine, dobutamine, norepinephrine, and epinephrine used for cardiac arrest, severe hypotension (low blood pressure), shock and sepsis. These are often known as "vasoactive" agents.
• Dextrose (often D50W, a solution of 50% dextrose in water), used to treat hypoglycemia (low blood sugar)
• Sedatives like midazolam, lorazepam, etomidate, and ketamine^[49][50] used to reduce the irritability or agitation of patients, to relieve symptoms of seizure, or provide procedural sedation
• Paralytics such as succinylcholine, rocuronium, and vecuronium, used when an emergency procedure such as rapid sequence intubation (RSI) is required^[51]
• Antipsychotics like haloperidol or ziprasidone, used to sedate combative patients
• Respiratory medications such as albuterol and ipratropium bromide used to treat conditions such as asthma and acute bronchitis
• Steroids such as hydrocortisone and methylprednisolone used to treat inflammatory respiratory conditions and adrenal crisis
• Cardiac medications such as nitroglycerin and aspirin are used to treat cardiac ailments such as angina and myocardial infarctions
• Diuretic medications such as furosemide to treat congestive heart failure and severe hypertension
• Antiarrhythmics such as amiodarone, adenosine, lidocaine and magnesium sulfate used to treat abnormal heart rhythms such as ventricular tachycardia and ventricular fibrillation
• Antiemetics such as promethazine or ondansetron used for nausea and vomiting
• Antidotes for a variety of toxins such as naloxone (opioids), pralidoxime (organophosphates), sodium bicarbonate (tricyclic antidepressants), and hydroxocobalamin (cyanide).
• Blood products and tranexamic acid in cases of hemorrhagic shock
• Broad spectrum antibiotics such as ceftriaxone or vancomycin for cases of sepsis
• Hormones like oxytocin to control post-partum bleeding

Skills by certification level

As described above, many jurisdictions have different levels of paramedic training, leading to variations in what procedures different paramedics may perform depending upon their qualifications. Three common general divisions of paramedic training are the basic technician, general paramedic or advanced technician, and advanced paramedic. Common skills that these three certification levels may practice are summarized in the table below. The skills for the higher levels automatically also assume those listed for lower levels.