A friend of mine recently observed that it seemed to be “disaster week in Maine” earlier this month. The National Guard, a large Urban Search and Rescue group and numerous other agencies were doing a huge collapsed-building drill at what was the Brunswick Naval Air Station; county Emergency Management offices were going through a major blizzard/ice storm disaster communications practice with local fire departments, amateur radio operators and others; and EMTs and paramedics from all over the state were gathering for continuing education at the Samoset Resort in Rockport. This all got me thinking about how many different kinds of emergency responders we have. I don’t know if my comments here will clarify things or just confuse people, but maybe I can bust a few myths.
A few nights ago I telephoned into the regular meeting of our local search and rescue group. Next week I have to go to Bangor and take a class to renew my CPR Instructor license. I just had occasion to chat with a relative who keeps referring to me as a paramedic. I am not a paramedic—and what they don’t understand is that I really don’t want the paramedics I cross paths with from time to time to think I am passing myself off as one. On top of that, I respond to an older neighbor with a minor first aid concern and am told, “You’re some kind of a nurse, ain’t you?” I am not a nurse, but to them, anybody who comes around with the band-aids must be a nurse.
So is there a real difference?
Territoriality among and between medical specialties and allied health care fields can be a real problem, but that’s a topic for another day. Let’s take a quick look at what some of these different responders can and cannot do, in brief, so I’ll have something to send to my friends who don’t “get” the differences. In no particular order:
When you call 911, the person answering the phone is a licensed Emergency Medical Dispatcher. They are current in CPR and have addition training, and may be able to help you manage your emergency over the telephone until help arrives. They are not just a clerk or a telephone operator! Stay on the telephone with your dispatcher until they tell you to hang up; the dispatcher may be a lot of help to you on scene, and they can relay anything you report about changes in the patient’s situation or other needs to the responding crew by radio.
In Maine, we have three levels of emergency medical personnel who normally respond to a 911 call: Emergency Medical Technician (EMT), previously called “Basic” EMT or EMT-B; Advanced EMT (AEMT) previously called EMT-Intermediate, and Paramedic. Your community may also be served by Emergency Medical Responders, previously called First Responders. Years (many years!) ago there was the job title of “Ambulance Attendant” or Ambulance Driver; that no longer exists, and nobody who responds in an ambulance is “just a driver.” EMR’s might respond in their private vehicles to local accidents, etc. and be met on scene by the ambulance crew.
An EMT, which is what I am, will normally ask questions and take vital signs to assess whether or not there is a life-threatening situation and will work to stabilize the patient and get him or her ready for transport to the hospital. They perform CPR, set up oxygen, apply splints, bandages, cervical collars or other external stabilizing equipment, and do a few other things. An EMT cannot start an intravenous line, intubate a patient (put a tube into the airway,) set up and read the strip on a cardiac monitor, or administer medications other than things like aspirin or an Epi-pen. Someone licensed as an AEMT can do many of these things but cannot administer most medications. A Paramedic has standing orders about which medications he or she can administer and when, and also has instructions to call Medical Control (meaning an emergency physician who works with that ambulance service) when more authority is needed or for other instructions.
When you call 911, you should understand that the EMT works under legal protocols and cannot simply do whatever you ask (I can tell you some crazy stories about Matinicus, of people thinking they can demand procedures I cannot do, but I’ll keep quiet. EMS providers are obligated to confidentiality as well). EMTs will not tell you what pills you should take for that pain and they will NOT (are you listening, islanders?) stitch a wound in the field.
The law in the state of Maine states that a licensed emergency care provider must not “hand off” patient care to someone with a lower level of license. For example, an EMT or Emergency Responder can pass their patient along to an AEMT or a paramedic, but it cannot work the other way.
This matters because some small towns, including some islands, in Maine have a Non-transporting EMS service, which means they have EMTs and perhaps other providers but no ambulance, and unlike most, they do not take their patients directly to the hospital but rather must pass them over to another agency for further care and transportation. If I, as an EMT responding to a dispatched 911 call, should need to send my patient to the mainland in a storm with the Coast Guard, I would have to accompany that patient aboard the Coast Guard vessel unless the USCG has among their crew an EMT, or has brought one from the mainland.
In many cases the patient does not need a paramedic. It is something of a myth that the higher level of licensure the better the care in all cases. The existence of the paramedic level does not mean that the lowly EMT is merely a driver or an equipment carrier. The paramedic can’t do any more than the “basic” EMT can for that sprained ankle; their real role is with critical calls. For a paramedic to be effective and to provide sophisticated interventions safely, he or she must use those advanced skills fairly often. Skills like intubation definitely can get rusty with disuse. Starting an IV in a sick person’s vein is not “like riding a bicycle.” Therefore, it is not true that we’d be better off if every last rural responder was a paramedic. If they don’t work in a location where there is sufficient call volume to keep those skills sharp it would be, in a sense, false advertising. The general assumption is that a paramedic can always be called when needed. That does assume a certain degree of civilization, though, and of course going into the “back country” means access to care is whole different ball game.
A Wilderness First Responder, Wilderness EMT, or anybody else with “wilderness” in their job description is responder has been trained to assist patients where quick transport to a hospital is not possible. These are commonly your outdoor-sports people—mountaineers, raft guides, camping trip leaders and such — but the basic principles of wilderness medicine can apply anywhere an extended transport time is the norm. A massive blizzard hitting a major city might put those city responders into what is temporarily a “wilderness” setting. Shipboard medical personnel, medics in some military contexts, and remote village health care staff in places like Alaska may utilize the same skills and methodologies. They certainly have the same mindset, which is “use what resources you’ve got, improvise if you have to, think on your feet, and don’t rely on a lot of equipment.” Wilderness protocols assume a transport time to “definitive care”—meaning a hospital, not just a pickup truck at the trailhead—is two hours or more. I’ll toss out that any time the weather is not “flyable,” a wilderness setting in the eyes of the law would include Matinicus Island. It would often include Monhegan and Isle au Haut and Frenchboro and Cliff Island and others, too.
By the way, back to the idea that higher licensure does not always mean better care: there are so many different types of specialized training and real-world experience among care providers, one must consider the circumstances. Physicians, for example, are not always ready to respond to emergencies. Many types of physicians routinely work in very structured environments with everything scheduled and organized (not to mention clean!) and dozens of nurses and others on hand to follow orders. They may know nothing about dealing with that remote hiker with a terribly painful dislocated shoulder suffering twenty miles from the nearest road, whereas an Eagle Scout with WFR training may be ready to assist with that.
Personally, if I get hurt, I hope there is a ski patroller around; they have some of the best training for responding to physical injury. A ski patroller is very much like an EMT with emphasis on cold weather and sports injuries. They respond for their employer, however, and will call a local EMS service to take their patient to a hospital once safely off the mountain. I have a lot of respect for these responders; they work in pretty demanding conditions despite how much they love their jobs!
A search and rescue (SAR) volunteer starts with a person who is comfortable outdoors, is in decent physical condition and knows how to spend time safely out in the weather. Often these are folks who enjoy outdoor recreation like hiking or skiing or who work outdoors such as surveyors and guides. SAR volunteers get specific training not only in things like map and compass skills, but in crime scene and evidence preservation, confidentiality and professional interaction with other agencies, and appropriate interaction with missing persons such as small children or dementia patients. Some SAR volunteers have additional medical training; all have had at least CPR and First Aid courses.
Some search and rescue personnel have advanced skills with very specific training, such as swiftwater rescue, search dog handling, and Urban SAR. Think Oklahoma City. Think World Trade Center. Those guys do a job quite different from those of us who walked around in Glenburn, Maine last spring, under the direction of the Game Wardens, trying to find Nichole Cable.
So, back to those islands I mentioned earlier, where transport to a hospital always takes so long. Can’t the islanders just call the helicopter whenever a patient needs to get off the rock? It isn’t that simple. The LifeFlight helicopter crew, which includes a critical care paramedic and a Flight Nurse (RN) as well as the pilot (who is responsible for the aircraft, not the patient,) is essentially a flying emergency room. They will respond to a call when life, limb, or eyesight is threatened and the weather is safe to fly. They cannot come in “any weather” (and spare me your rant about what you “saw back in ‘Nam.” I’ve heard it. The pilots do not fly into known danger.) They will not come for the non-critical injury and are never just a ride back to civilization. They do not search. Other helicopters from other agencies, such as the U.S. Coast Guard and the Maine Forest Service, have other capabilities and provide different services. These might engage in search or might even rescue a stranded patient with a line beneath the aircraft, but they are not set up to provide critical care in-flight. In no case will a helicopter crew be sent to a relatively minor complaint.
Specialty crews for particular types of emergencies will often go wherever they are needed, regardless of home base. Just a few examples of these include extrication crews with special tools, water-rescue experts, wildland firefighters, people knowledgeable about high-angle rope rescue, those prepared to deal with hazardous materials, and those with experience in extreme environments, such as desert or Arctic conditions; they may find their expertise requested far from home. Some also combine work with play, volunteering in places like the Grand Canyon or Denali National Park.
There is a lot of cross-over, because people who have a passion for this kind of work often are involved in multiple types of response or work for multiple agencies. Rural paramedics often work for several towns and respond as needed. Paramedics and EMTs may also be firefighters. Firefighters and medical responders may be full-time professionals based in a station working for a municipality, they might work full or part-time for a privately-run (non-municipal) ambulance service, or they might be persons with unrelated jobs who respond whenever they can. Some are paid and some are entirely volunteers. Most people who have been in emergency medical services for a long time advance to higher levels of licensure, but not always: I have been a “basic” EMT for 19 years because of the realities of where I live and work. I’m not the best example of this but remember that the person with the most sophisticated education is not always the one with the most real-world experience. Some EMTs and paramedics are also nurses; some work in hospitals or other health-care settings (the overlap and differences between what a paramedic can do and what an RN can do are hopelessly complex). Some EMTs are also wilderness responders, SAR volunteers, or rural volunteer firefighters.
However, how they respond and what they— I mean what WE—are legally expected and permitted to do depend upon where and for whom we are responding. Nobody is supposed to be a freelancer.
That should make it all clear as mud. I’m sure I’ve inadvertently left somebody out. Please accept my apology there. Let me take this opportunity to urge anybody who can to take a CPR course, join the local volunteer fire department, become a WFR if you like to play outside, or help responding agencies in any way you can.
Eva Murray, who has been a patient of Rockland EMS and LifeFlight, thanks responders at every level.
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