Emergency Medical Services and Paramedic Care

01Purpose and scope

• This manual supports the course Emergency Medical Services and Paramedic Care. It is a working reference for people who respond to emergencies outside a hospital, including paramedics, advanced emergency medical technicians, emergency medical technicians, supervisors, and the medical directors and quality staff who oversee them. It describes what the work looks like on a real call, from the first radio tone to the moment a patient is transferred to a receiving team and the paperwork is closed.
• The manual covers scene safety, patient assessment, treatment in the field, transport decisions, handoff, documentation, and the review that follows. It does not teach drug doses, device settings, or the physical skills of airway management or extrication. Those belong in supervised training and in the protocols your agency has approved. Where this manual mentions a procedure, treat the mention as a pointer to the approved source, not as the source itself.
• This guidance does not replace qualified professional judgment, approved medical protocols, or the direction of an online or on-site medical control physician. Scope of practice, drug formularies, and transport rules are set by state or regional authorities and by your agency, and they change. Check the current authoritative source for your jurisdiction before acting on any rule described here.

02Core principles

• Scene safety comes first. A crew that becomes a patient cannot treat anyone. Before approaching a patient, the crew confirms that traffic is controlled, that hazards such as downed wires, fuel, unstable structures, violent persons, and hazardous materials are identified, and that law enforcement or fire has been requested when the scene requires it. The people who make this call are usually the first arriving crew member, and they should not be pressured to enter an unsafe scene because the patient appears to be in critical condition.
• Assessment is continuous, not a single event. The first impression, sometimes called the general impression, shapes the priority of the next steps. A patient who looks well but is hypoglycemic, or a patient who is talkative but has a rapidly falling blood pressure, can deteriorate within minutes. Reassessment after every intervention and at regular intervals during transport is part of the standard of care, not an optional extra.
• Treatment follows the recognized sequence of life threats. Airway, breathing, circulation, and disability are addressed in order of immediate danger, with exposure and environment considered throughout. Within that sequence, the crew matches interventions to what the patient actually shows, not to a checklist that runs regardless of findings.
• Transport is a treatment decision. Choosing a destination hospital, a trauma center, a stroke or cardiac center, or a non-emergency clinic affects outcomes. Time spent on scene for an intervention that cannot be done en route is time that the patient does not get back. Choosing to leave early or to wait is a clinical judgment that must be made and documented.
• Patient dignity, privacy, and informed consent apply in every call. Patients who have capacity may refuse care, and the crew must explain the risks in plain language, confirm understanding, and document the refusal. Patients who lack capacity are treated under the implied consent and emergency provisions that apply in your jurisdiction.

03Planning and preparation

• Preparation starts before the tone drops. Each crew checks its vehicle, equipment, and medication inventory at the start of a shift. Oxygen levels, suction function, monitor battery charge, and the presence of required supplies are confirmed and logged according to agency policy. A crew that discovers a missing item on scene has lost time it could have used for patient care.
• Crews also prepare mentally by reviewing their area. Knowing the local hospital capabilities, typical diversion patterns, rural travel times, and the location of closest specialty centers allows faster decisions. Many agencies publish current destination guidance and update it when hospitals change capacity. Use the current version, not memory from a previous year of service.
• Roles are agreed before arrival where possible. In a two person crew, one member often leads patient care and the other handles scene management, equipment, and communication with dispatch or other responders. In larger incidents, the first arriving unit usually takes incident command under the agency's incident command system, and the role is handed off formally when a supervisor arrives. Clear role assignment prevents two people from giving the same medication or both trying to manage the airway.
• Equipment selection depends on the call type and the setting. A rural ambulance may carry more supplies for long transports and carry fewer specialty items. An urban fire-based unit may reach patients faster but have less capacity for extended transport. Mass casualty and disaster kits are a separate category. Staff must know where those kits are stored and how they are deployed, and they should practice with them at least as often as the agency requires.
• Staffing and fatigue are planning issues too. A crew that is tired or working a long shift makes more errors in drug calculations, documentation, and communication. Supervisors should recognize this and plan relief, especially after a difficult call.

04Recommended workflow

1. 1
   : Receive and interpret the dispatch information. Note the call type, the number of patients, the reported hazards, the address, and any known caller findings. Ask the dispatcher for additional details when the information is vague, and plan the approach accordingly. Keep the initial radio report short and factual.
2. 2
   : Assess the scene before entering. Look for traffic, bystanders, weapons, smoke, gas odors, electrical hazards, and the mechanism of injury if it is a trauma call. Decide whether the scene is safe to enter, whether to stage nearby, or whether to request assistance first. Document the decision and the time.
3. 3
   : Perform the initial patient assessment. Form a general impression, then assess responsiveness, airway, breathing, and circulation. Obtain a set of vital signs and a focused history, including chief complaint, onset, medications, allergies, past history, and last oral intake. Record times for each finding because later clinicians will need them.
4. 4
   : Treat the immediate threats according to protocol. Address airway and breathing problems first, then circulation, including bleeding control and fluid decisions as directed by protocol. Apply monitoring and obtain a twelve lead electrocardiogram where indicated and where your protocols allow. Intervene only within your scope and with the authorization your protocols require.
5. 5
   : Reassess and decide on transport. Repeat vital signs and the focused exam after each significant intervention. Choose the destination based on the patient's condition, the availability of specialty care, and the transport time. Notify the receiving facility with an estimated arrival time and a short description of the patient and interventions. Use the agency's approved handoff format, often a structured mnemonic such as SBAR or MIST for trauma.
6. 6
   : Monitor during transport and communicate. The attendant tracks vital signs, watches for deterioration, adjusts treatment within protocol, and keeps the driver informed of changes that affect the route. If the patient needs an intervention that cannot be done safely in the moving vehicle, the crew must make that decision early rather than late.
7. 7
   : Hand off and close the call. Transfer care to the receiving team with a verbal report and a written record. Confirm that the receiving clinician has accepted care, obtain signatures as required, clean and restock the vehicle, and complete documentation before the end of the shift if possible. Note any equipment that needs repair or replacement.

05Quality checks, risk controls and compliance

• Quality checks happen at several points. During the call, a second crew member or a supervisor can verify drug names, doses, and patient identifiers before administration. After the call, the medical director or a designated reviewer checks the record for completeness, protocol adherence, and timing. Many agencies use a percentage of charts for random review and a larger sample when a patient has a serious adverse event.
• Medication safety is a major risk area. Use the agency's approved drug list, verify concentrations, record the dose, route, time, and the patient's response, and document waste according to policy. Controlled substances carry additional accountability requirements that vary by jurisdiction and by federal rules where they apply. Check the current requirements from the agency and the relevant regulator.
• Infection control, sharps handling, and personal protective equipment are standard expectations on every call. Staff should follow the agency exposure control plan and report any exposure promptly so that post exposure evaluation can begin.
• Patient privacy is governed by law. In the United States, handling of protected health information is subject to federal rules and to state requirements that may be stricter. Share information only with those who need it for care, payment, or operations, and follow your agency's policy on mobile devices, photographs, and social media. Consult your privacy officer and the current official guidance when the situation is unclear.
• Clinical risk controls include clear communication of the medical control contact, documented authorization for any procedure outside standing orders, and a method for reporting near misses. A crew that feels uncertain about a decision should contact medical control rather than proceed on assumption. Some controls, such as stopping transport to treat on scene, require explicit authorization under local rules and should not be improvised.

06Collaboration and documentation

• Paramedics work alongside firefighters, police, dispatchers, hospital staff, and sometimes public health or social services. Each group has its own language and priorities. Early, plain communication prevents duplicated effort. A brief scene update, a shared understanding of who is handling patient contact, and a clear handoff make a difference in outcomes.
• Documentation is both a clinical tool and a legal record. A good patient care report states what was found, what was done, when it was done, the patient's response, and the reason for each decision. It avoids vague terms such as normal or unremarkable without specific findings. Times should be recorded from the clock on the monitor or the agency's standard source, and corrections should follow the agency's amendment process rather than overwriting the original entry.
• Electronic patient care records are common, and most follow a national data standard that supports reporting to state and national databases. Enter data in the right fields, avoid copy-paste errors, and check the record before leaving the hospital if the system allows it. Incomplete data reduces the usefulness of the record for quality review and for public health reporting.
• Collaboration with the receiving hospital continues after the handoff. Ask for outcome information when your agency has a feedback process. Many hospitals will share results on selected cases, which helps crews see whether their decisions worked. Respect confidentiality when discussing cases outside the approved process.

07Measures and continuous improvement

• Agencies measure performance using indicators that reflect the care they provide. Common measures include response time, time to scene, time to first treatment for critical conditions, documentation completeness, protocol compliance rates, and patient outcomes such as return of spontaneous circulation or survival to discharge for specific conditions. Each measure has limits. Response times depend on geography, call volume, and dispatch practice, so they should be interpreted in context and not used alone to judge a crew.
• Choose indicators that the crew can influence and that connect to a clear decision. For example, time from arrival to a documented glucose check for patients with altered mental status is more actionable than a broad survival figure that depends on many factors outside the field. Define each measure precisely, including the numerator, denominator, and data source, before collecting it.
• Continuous improvement works best when feedback is timely and specific. Monthly case reviews, peer review meetings, and simulation sessions give crews a chance to discuss decisions without blame. When a review identifies a problem, the agency should decide whether the cause is an individual performance issue, an equipment or staffing problem, a protocol gap, or a system issue, because each needs a different response.
• Trade-offs appear in every improvement effort. Faster transport may reduce on scene time but increase the risk of a crash. A longer transport to a specialty center may improve definitive care but delay treatment for a patient who could be stabilized locally. Quality work involves making these trade-offs explicit and reviewing whether they produced the intended result.

08Common mistakes and how to prevent them

• Entering an unsafe scene is a frequent and serious error. Crews sometimes rush because a patient appears to be in arrest or because a bystander is pleading for help. Prevention relies on a fixed habit: stop, look, and decide before you enter, and request support early when the scene is unclear. Supervisors should reinforce this habit in training and in debriefing.
• Failing to reassess is another common mistake. A patient whose condition was stable on arrival may deteriorate during packaging or transport. Set specific reassessment points, such as after each medication, before moving the patient, and at regular intervals en route, and record them.
• Medication errors occur through confusion between similar drug names, miscalculated doses, or administration without verification. Prevention includes reading the label aloud, using a second check for high risk drugs, and keeping the medication area organized. Report near misses so that the system can learn from them.
• Incomplete or inconsistent documentation weakens both care continuity and legal protection. Typical problems include missing times, unclear patient refusal details, and narrative text that does not match the vital sign record. Prevention involves completing the report before going off duty, using the agency checklist, and reviewing the report against the monitor data.
• Poor handoff leaves the receiving team without key information. Crews sometimes rush the verbal report or skip details such as the time of symptom onset or the last dose of a medication. Using a structured format and asking the receiving staff to repeat back key points helps prevent this.

09Practical checklist

• Confirm that the scene is safe, that hazards are identified, and that support has been requested when needed.
• Complete the general impression and initial assessment, and record the time of each finding.
• Verify equipment, medication inventory, and the vehicle readiness status before the shift and after each call.
• Reassess the patient after every significant intervention and at the intervals set by protocol.
• Confirm the destination decision with the patient's condition, transport time, and specialty availability.
• Give a structured verbal handoff and obtain confirmation that the receiving team has accepted care.
• Complete the patient care report before going off duty, with times, interventions, and patient response.
• Report exposures, near misses, equipment failures, and protocol concerns through the agency process.

★Learning sources

• Micro Degree: Emergency Medical Services and Paramedic Care
• Micro Degree: Healthcare Administration Practice
• Micro Degree: Physiotherapy Assistant Operations
• Micro Degree: Cardiac Care Support