Advanced care options in EMS?

[EMS5]

Wake County (NC) EMS seems to have an interesting program that got started in the beginning of 2009. They have a small group of "Advanced Care Paramedics" that provide backup to the counties ALS transport system.

These paramedics are primarily responsible for responding to critical patient calls along with the ambo and providing an extra set of experienced hands in managing the patient. They also do a large amount of community and preventative medicine, visiting frequent fliers and working to reduce non-urgent and preventable 911 calls.
http://www.wakegov.com/ems/staff/app.htm

Vaguely, I have heard tell of other programs starting pilot programs or SOP's for stuff such as 18 lead ECG, expanded drug treatment options, limited privilege to prescribe, advanced assessment (lab/CXR interpretation), limited field diagnosis, wound closure, and others.

What is going on with your local department/agency and state system as far as new pilots and advanced care options?

EMS docs and medical directors, are there any new tools you are planning on adding to your providers' arsenals in the near future?

Field providers, is there anything you would like to added to your arsenal that could improve patient care in the field?

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[jwk]

Wake County (NC) EMS seems to have an interesting program that got started in the beginning of 2009. They have a small group of "Advanced Care Paramedics" that provide backup to the counties ALS transport system.

These paramedics are primarily responsible for responding to critical patient calls along with the ambo and providing an extra set of experienced hands in managing the patient. They also do a large amount of community and preventative medicine, visiting frequent fliers and working to reduce non-urgent and preventable 911 calls.
http://www.wakegov.com/ems/staff/app.htm

Vaguely, I have heard tell of other programs starting pilot programs or SOP's for stuff such as 18 lead ECG, expanded drug treatment options, limited privilege to prescribe, advanced assessment (lab/CXR interpretation), limited field diagnosis, wound closure, and others.

What is going on with your local department/agency and state system as far as new pilots and advanced care options?

EMS docs and medical directors, are there any new tools you are planning on adding to your providers' arsenals in the near future?

Field providers, is there anything you would like to added to your arsenal that could improve patient care in the field?

No offense intended here. Interesting concept, noble goals, but WAY off base.

I think much of this is FAR outside the realm of EMS, and far outside the scope and education of paramedics. Prescriptive authority - no way. (I take it that's not happening anyway since it would require a change in state law) Interpretation of CXR's and labwork? C'mon. I understand additional help on critical calls, but really, you're moving from your admitted area of expertise (EMS) to an area you really have no business getting involved with (essentially community health nursing), and or into the usual scope of practice of PA's and NP's, post of whom have master's degrees.

 

[EMS5]

I believe the prescriptive authority was in reference to TEMS providers, that is the only situation where I could see anything relatively close to prescriptive authority granted to providers. I definitely agree that EMS providers have no place prescribing medications or interpreting CXR's in the emergent setting, however I could justify limited labwork with the advent of portable devices for testing basic labs.

I watched the video on Wake County's website, and they verbatim said that what they were trying to do is bridge the gap between community health nursing and EMS. However, they also said explicitly that they aren't giving their paramedics a wider scope of practice or expanded skill set necessarily, but making the experience available to increase the productivity of the system and protocols in place.

I am looking for any such programs that allow advanced assessment or treat-and-release for urgent care issues that require care beyond the level of the paramedic....I think that if any exist they would have to be outside of the U.S. as you said because of state laws. If I find anything I will be sure to post a link.

 

[DSStudent]

It is an interesting concept and in fact they have something similar in the UK.
http://en.wikipedia.org/wiki/Emergency_care_practitioner
But it seems to me that this is something more suited to a mid-level practitioner. So would you use existing NP/PA's or create a new type of advanced practice level of paramedic?

 

[deleted6669]

there are already a few states that credential field pa's such as pennsylvania and virginia.
several others allow pa's who are current emt-basics to challenge the emt-p exam.
there are also programs that allow em or critical care pa's to do a 2 week emt-p course then take the natl exam.
a pa or np without prior training and experience in field ems should stay out of the field in my opinion....and medics shouldn't be suturing and writing scripts....
emedpa, pa-c, emt-p

 

[COMedic2Doc]

Ok, so I'll go ahead and chime in.... A little background first, I have ten years of experience working in ER, ICU, and the field as a Paramedic. I am currently working in Iraq as a Remote Duty Medic. What does Remote Duty mean? To boil it down, I dispense medications within protocols, and see employees as their primary care provider while they are working in Iraq. I have done I&D procedures, sutured lacerations, etc while being in Remote Duty Medicine. Are Advanced Paramedics or Remote Duty Medics a good idea? YES, absolutely.

As in the field, most PAs would be uncomfortable to an extent working in Iraq in this setting, as CXRs, labs, etc are not readily available on a routine basis. Can I refer patients to the military hospitals (TMCs and CSHs) for lab work, X-Rays, etc? Yes, however many times as their primary provider I have to start justifying why I am referring them for consults, etc very quickly (usually just after getting in the door, unless they are a critical patient) for life, limb, and eyesight threats.

Being in Iraq has only done one thing for me, it has made me firmly decide to come home, finish my degree, and apply to a D.O. program or PA program. This setting is NOT for every Paramedic, and to be quite honest many get frustrated very quickly because they have to think more from a clinician stand-point, not a field provider stand-point. To me for those of us that thrive in this environment, only shows that we should either stay in Remote Duty Medicine or apply to a clinician program. Working in the setting that the OP suggests has only showed me that I want to learn the classroom portion of being a clinician to help me develop more, professionally.

Is the Remote Duty Medicine setting appropriate for remote settings in the US? This is a huge debate that honestly could take many turns before it is fully answered. Paramedics for the most part are not educated in the scientific and clinical setting, we are field providers and are trained to think quickly, treat quickly, and get the patient to the next echelon of care. Is Remote Duty Medics, like myself, suitable for such areas as Antarctica, Iraq, and other areas similar to this around the world? Yes, absolutely and like myself the right Medic will thrive in these conditions. So, my answer is that I agree that PAs with a Paramedic background or training are best suited for the OP's proposed environment, but Paramedics can also thrive in Remote Duty Medicine as well. To avoid making this post longer than it already is, I have purposefully avoided discussion about my protocols, formulary, etc and if you'd like more info, feel free to PM me.

 

[EMS5]

there are already a few states that credential field pa's such as pennsylvania and virginia.
several others allow pa's who are current emt-basics to challenge the emt-p exam.
there are also programs that allow em or critical care pa's to do a 2 week emt-p course then take the natl exam.
a pa or np without prior training and experience in field ems should stay out of the field in my opinion....and medics shouldn't be suturing and writing scripts....
emedpa, pa-c, emt-p

I have seen where starting in 2012, Pennsylvania will actually begin credentialing physician extenders (PA's) and RN's for field care.

I definitely agree that PA's and NP's without em/ems experience have no place in the field. I would go as far as to say that most physicians and health care professionals need to stay away from EMS without prior training. I had a podiatrist at the scene of an mvc a few months ago telling me how to manage a multi-trauma patient...didn't want to be rude but that's a major CYA issue if he had become involved with patient care.

You disagree with EMS suturing...what are your thoughts about other methods of wound closure? Currently our state EMS protocol allows for ALS providers to utilize stapling, dermabond, and steri-strips in special situations.

 

[deleted6669]

You disagree with EMS suturing...what are your thoughts about other methods of wound closure? Currently our state EMS protocol allows for ALS providers to utilize stapling, dermabond, and steri-strips in special situations.

I would just be concerned about the following:
1. harder to do a sterile closure in the field
2. easier to miss an fb or tendon lac in suboptimal conditions(poor lighting)
3. field providers might feel more rushed to complete the repair to get back into service and might not adequately expose, irrigate, revise wound borders, etc
4. unless you do it frequently(like any skill) it's hard to stay proficient. we did a trial of letting er nurses suture and had to stop it because of higher infection rates, dehiscence rates, poor cosmetic outcomes, etc. not the nurses fault. many providers(myself included) refused to sign off on someone elses work so only the lazy providers utilized this and so they didn't get much practice.
5. stapling: say a scalp wound is deeper than appreciated and needs to have the galea closed....
6. some wounds and some pts require abx prophylaxis( or td) after closure and medics can't provide this.
7. some pts require special skill to close lacs(old lady on prednisone with tissue paper skin for example). see #4 above.
8. dermabond for simple linear forehead lacs that approximate well and are clean/well irrigated/etc is probably ok assuming the pt doesn't need an ed eval for their head/neck injury.
9. if steristrips are only used for superficial wounds( and you know what a superficial wound is) then they are ok as well.

to comedic2doc: if you think the remote medic gigs for emt-p are good in iraq/alaska/antarctica/etc you should look at the ones offered to pa's....WOW...it's easy to make 150k+ working only 6 months/yr. and scope of practice is whatever you want short of running an o.r.

 

[EMS5]

I would just be concerned about the following:
1. harder to do a sterile closure in the field
2. easier to miss an fb or tendon lac in suboptimal conditions(poor lighting)
3. field providers might feel more rushed to complete the repair to get back into service and might not adequately expose, irrigate, revise wound borders, etc
4. unless you do it frequently(like any skill) it's hard to stay proficient. we did a trial of letting er nurses suture and had to stop it because of higher infection rates, dehiscence rates, poor cosmetic outcomes, etc. not the nurses fault. many providers(myself included) refused to sign off on someone elses work so only the lazy providers utilized this and so they didn't get much practice.
5. stapling: say a scalp wound is deeper than appreciated and needs to have the galea closed....
6. some wounds and some pts require abx prophylaxis( or td) after closure and medics can't provide this.
7. some pts require special skill to close lacs(old lady on prednisone with tissue paper skin for example). see #4 above.
8. dermabond for simple linear forehead lacs that approximate well and are clean/well irrigated/etc is probably ok assuming the pt doesn't need an ed eval for their head/neck injury.
9. if steristrips are only used for superficial wounds( and you know what a superficial wound is) then they are ok as well.

1. This isn't my area of expertise, however multiple pa's and docs at our local hospital that I have talked with have said that there isn't a notable difference in post-closure infection. It would be too much of a pain (if even possible) to create a sterile field in the back of an ambulance.
2. Our newest ambo is VERY well lit in the back (borderline blindness), hopefully agencies wouldn't have crews attempting this in an older, less equipped unit.
3. Agreed. Most medics (myself included generally) don't like to "stay and play" on minor injuries that could be taking timely ALS service from a critical patient.
4. Again, agreed. I have procedures in my scope that I haven't ever practiced and others I haven't done but once or twice in my career.
5. Something that I think would be a transport case due to potential bleeding control issues due to wound closure.
6. Tactical and wilderness medics in my state (although a special breed) can dispense certain antibiotics in emergent situations with and without OLMC. Perhaps OLMC for abx or refer to urgent care/ED or PMD?
7. Agreed. These need to be sutured in the emergency dept and hopefully protocol would be written for these and others (coumadin, etc)
8. Agreed, if negative MOI and field r/o protocol for head/c-spine injury
9. Agreed. Again, something that requires clinical training/experience.

 

[KD1655]

In NJ, we are a bit spoiled in that the closest hosptial is usually within 15 minutes and the closest trauma center (level I or II) is, at most, a 30 minute drive. That being said, we really do not have a need for "advanced" paramedics and the intermediate EMT levels do not even exist in NJ because of the ~100% EMT-P coverage statewide and the access to definitive care at a hospital very quickly. However, to get involved in the discussion...

I have seen where starting in 2012, Pennsylvania will actually begin credentialing physician extenders (PA's) and RN's for field care.
QUOTE]

NJ already credentials RNs for field work; they are called MICNs (Mobile Intensive Care Nurses) and mostly do critical care transport. However, they are not restricted to CCT and I have seen many MICNs working along side their MICP (Mobile Intensive Care Paramedics aka NREMT-Ps) on the paramedic truck. While I am not certain, I believe that the prereqs are 1. (obviously) a NJ RN license 2. At least 1 year of critical care nursing experience; last time I checked, they were accepting ER experience as well. 3. A number of common ALS classes including ACLS, PHTLS/ATLS, PALS, etc. 4. I think about 100 hours experience riding an ALS truck with a paramedic preceptor.


Also, check out some of the stuff that paramedics are doing in Australia...they are leaps and bounds ahead of their stateside cousins. For example, I do believe that they allow their medics to administer nebulized narcotics for pain relief and allow them limited prescibing ability. However, it is my understanding that the paramedic certification is only achieved after 4+ years of post-secondary schooling so I guess they may be somewhat analogous to our PA's in the field....

 

[COMedic2Doc]

to comedic2doc: if you think the remote medic gigs for emt-p are good in iraq/alaska/antarctica/etc you should look at the ones offered to pa's....WOW...it's easy to make 150k+ working only 6 months/yr. and scope of practice is whatever you want short of running an o.r.

Iraq has been a decent experience, and I have a close friend that will probably stay a Remote Duty Medic for life. Personally, I'm more into advancing to the next level, as I've solidified that stepping up to a clinician level is for me. I definitely think I'll end up in military medicine, but would like to do more state-side work (working 7 days a week, 12 hours a day, and then being on call every night gets old real quick, especially after my first year here). I've actually known PAs and Foreign MDs here that are making at least 150k a year here .

 

[deleted6669]

i've actually known pas and foreign mds here that are making at least 150k a year here .

not 150k/yr.
150k for 6 months.

 

[COMedic2Doc]

not 150k/yr.
150k for 6 months.

Not too surprising .

 

[DSStudent]

There has been some discussion in my state about a BS program in EMS with a focus in Critical Care and maybe later a program to put these Critical Care Paramedics into PA programs. It's all just talk right now with no definite plans set.

 

[KD1655]

There are a handful of EMS Bachelor programs in which students graduate with their NREMT-P certs. The only program that I am familiar with is the one at UMBC in Maryland. Students get some pretty cool critical care experience like flying with the Maryland State Police Aviation Unit. I know that a couple of alums from this program are currently practicing physicians or in medical school. I am sure that the same is true for PA school. In my state (NJ) there is currently quite a few bills being formulated by the legislator that affect EMS. One of the notable ones is to do away with certifications and move toward licesure for EMT-Bs and MICPs, which are currently the only two levels of certification.

 

[EMS5]

I looked at a couple of bachelor programs in EMS...ended up staying local due to financial and family reasons...a couple of other ones in include western carolina university, univ of texas health sciences center, south alabama, and george washington university...seems like a good idea for those who know they want to go into EMS and don't want the biology or some other degree

 

[KD1655]

I only know about the UMBC program because I applied there and went through the paramedic application process; it seems like they really have their heads on straigh there. The paramedic program interview was done by the paramedic program coordinator, the department chairman, and I think two EM docs. After being accepted to the program, I decided to pursue biomedical engineer. I remember that the paramedic program coordinator telling me that a few of the alumni have went to medical school but I think all of them went to osteopathic programs. Do you think that allopathic programs would look down on a paramedic BS program? With regards to the list of schools that EMS5 listed above, I am not sure that all of them offer paramedic programs, I think the some of them (I know GWU for sure) only offer an EMS administration option.

 

[EMS5]

I haven't looked at the specifics of each program, so they may well only have an admin or management track. I almost think that allo schools look at paramedics and their BS programs in the same view as nursing, respiratory therapists, clinical/lab science and the such... graduates of the program have been trained (rather extensively in the case of the BS program) in this career, which has a general shortage especially in urban areas.

I know a couple of docs who got their starts in EMS, and it seems that osteopathic schools are generally more friendly towards paramedics who have been around the block a time or two. I may be slightly biased though since my top 2 schools are on allo and one osteo

 

[Paseo Del Norte]

not 150k/yr.
150k for 6 months.

My experience has been somewhat different. The trend I saw was a push to hire providers from countries such as the Philippines and pay them peanuts to do a job that a "western" provider would only consider for a solid six digit salary.

 

[deleted6669]

My experience has been somewhat different. The trend I saw was a push to hire providers from countries such as the Philippines and pay them peanuts to do a job that a "western" provider would only consider for a solid six digit salary.

A pa friend of mine spent a yr in sudan with an independent contractor group (cough, cough mercenary organization) and made 270k in 1 yr in which he saw a total of 13 pts.

 

[Paseo Del Norte]

A pa friend of mine spent a yr in sudan with an independent contractor group (cough, cough mercenary organization) and made 270k in 1 yr in which he saw a total of 13 pts.

This has not been my experience, however. Of course, I was in the Afghan theatre working with companies that were not owned by Americans or the British.

 

[deleted6669]

This has not been my experience, however. Of course, I was in the Afghan theatre working with companies that were not owned by Americans or the British.

the american groups( blackwater, etc) are paying 120k to drive a truck so they pay medical folks a lot more.

 

[ArkansasRanger]

I think I'd just assume drive a truck for six months at 120k than PA/MD/EMT for six months at 120k, lol.

 

[Paseo Del Norte]

I found most of the driving was done by locals who knew the country and much of the security was provided by the Nepalese. One of the big security companies in theatre SSSI had a huge pool of Nepalese who did a variety of security missions. This seemed to work well as they could communicate with the locals. Apparantly the Nepalese were good at a language called Urdu. Urdu is apparently very similar to Dari and Pashto and I think it is a major language in Pakistan. My employer had locals do most of our driving.

 

[Apollyon]

I found most of the driving was done by locals who knew the country and much of the security was provided by the Nepalese. One of the big security companies in theatre SSSI had a huge pool of Nepalese who did a variety of security missions. This seemed to work well as they could communicate with the locals. Apparantly the Nepalese were good at a language called Urdu. Urdu is apparently very similar to Dari and Pashto and I think it is a major language in Pakistan. My employer had locals do most of our driving.

Urdu is Hindi written in Arabic. This is similar to Yiddish, which is Hebrew written in German.

 

[MICT]

I've read about Wake County's program before and I'm very excited about it. It looks like a definite step in the right direction for EMS, that is, the transition from Emergency Medical Services to Mobile Health Services and I applaud their efforts and courage in taking the first step in this tremendous undertaking. With any luck, this will be one of the motivating forces that drives educational standards up and forces services to begin accepting nothing less than a four year degree from a university.

 

[EMS5]

Eh. I can't say I agree with a universal move to requiring the bachelors for paramedics. I think that the current level of care provided by paramedics is sufficient for what we see on a day to day basis. In more urban systems, such as the Raleigh-Durham metro area, there could be a benefit to having paramedics available with a wider knowledge base in pathophys, pharmacology, epidemiology, etc to reduce unnecessary transports, but definitely not an effective use of resources to have sent on every call.

 

[Paseo Del Norte]

Eh. I can't say I agree with a universal move to requiring the bachelors for paramedics. I think that the current level of care provided by paramedics is sufficient for what we see on a day to day basis. In more urban systems, such as the Raleigh-Durham metro area, there could be a benefit to having paramedics available with a wider knowledge base in pathophys, pharmacology, epidemiology, etc to reduce unnecessary transports, but definitely not an effective use of resources to have sent on every call.

I would like to see an AAS be the entry point into practice. This along with licensure would put the medic on par educationally with the RN and some of the allied health providers such as respiratory therapists.

It would be my hope that this could be a bargaining chip for the medic when competing with nursing counterparts. Clearly, this potentially threatens me as a nurse, but a little competition is never a bad thing.

I am not sure mandating a four year degree for a provider who has a very linear and algorithm based approach for health care delivery is really needed in most cases when considering the primary role of the paramedic in the United States. This also applies to other providers such as nurses. Don't take this as bashing, it's just the way it is.

 

[EMS5]

Agreed. Between protocols, ACLS/PALS/PHTLS, and online medical direction, there is very little medical decision making to be done by the paramedic.

 

[MICT]

I would like to see an AAS be the entry point into practice. This along with licensure would put the medic on par educationally with the RN and some of the allied health providers such as respiratory therapists.

It would be my hope that this could be a bargaining chip for the medic when competing with nursing counterparts. Clearly, this potentially threatens me as a nurse, but a little competition is never a bad thing.

I am not sure mandating a four year degree for a provider who has a very linear and algorithm based approach for health care delivery is really needed in most cases when considering the primary role of the paramedic in the United States. This also applies to other providers such as nurses. Don't take this as bashing, it's just the way it is.

I disagree with you on that. I think there is absolutely everything right with mandating a four year degree, and counter that that linear approach to healthcare delivery is a result of the poor educational standards; not the other way around.

Furthermore, I would argue that paramedics whose care is linear and algorithm only or principally are not fulfilling their jobs as intended. In my experience, the most proficient paramedics were the ones who didn't try to tie their patients down to one specific protocol.

Looking at the UK model, we see that four-year degree paramedics are regarded as independent practitioners who bring a significant degree more to their patients than cookbook medicine. By having that additional education, they are allowed to make sound decisions for their patient that acts in his or her best interest; not simply treat per protocol and transport or sign a refusal.

Regardless of how additional education would alter protocols in the States, it's in the best interest of paramedics and paramedicine to raise their educational standards so they can provide more competent care to their patients; and also because only by raising educational standards will the pay for paramedics increase.

 

[Paseo Del Norte]

I disagree with you on that. I think there is absolutely everything right with mandating a four year degree, and counter that that linear approach to healthcare delivery is a result of the poor educational standards; not the other way around.

Furthermore, I would argue that paramedics whose care is linear and algorithm only or principally are not fulfilling their jobs as intended. In my experience, the most proficient paramedics were the ones who didn't try to tie their patients down to one specific protocol.

Looking at the UK model, we see that four-year degree paramedics are regarded as independent practitioners who bring a significant degree more to their patients than cookbook medicine. By having that additional education, they are allowed to make sound decisions for their patient that acts in his or her best interest; not simply treat per protocol and transport or sign a refusal.

Regardless of how additional education would alter protocols in the States, it's in the best interest of paramedics and paramedicine to raise their educational standards so they can provide more competent care to their patients; and also because only by raising educational standards will the pay for paramedics increase.

I will continue to disagree. We have paramedic programmes that are less than a thousand hours total and require absolutely no formal (college) education. Moving to mandate a four year degree as entry into practice at this point is rather silly when we do not even have a two year degree or curriculum as an established standard.

I suspect mandating an AAS would be an uphill battle, let alone a four year degree for paramedics. I appreciate your enthusiasm; however, we must be pragmatic in our approach. Perhaps, a four year degree can be discussed at a later date?

Without any real experience, I cannot comment on the UK model. I worked with South African B-tech medics who were four year qualified paramedics and they delivered very good care IMHO.

 

[deleted6669]

some states already require an a.s. for medics.
I work on the border between 2 states. 1 state has the a.s. mandate and the other does not.
the state that does not is generally considered to have better medics but this may be more related to scope of practice between adjacent counties in adjacent states.
that being said I also favor the a.s. requirement to be a medic. I was an anomaly in my medic course as I already had a bs and no one else did. it was a cert program, 1200 hrs over 1 yr. most of my classmates turned into excellent medics but there were a few fire service volly type yahoos who would have been screened out by a requirement to complete other prereqs for an a.s. degree...also medics should be licensed and should be on par with a.s. level rn's, both in terms of pay and respect.

 

[EMS5]

Licensure should (and I hope will) become the universal credential level for a paramedic, instead of having some states certify and some states license.

I have agree to paseo on the entry level paramedic requirements. Switching to a required B.S. for paramedics would throw the entire system into chaos. Take into consideration how call volume is divided. 75% of calls are BLS and require no paramedic intervention. 15-20% of calls are medium priority ALS, patients receiving D50, minor-moderate traumas, stable/responsive to treatment. There are very few critical care calls (resp/cardiac arrest or imminent, major trauma, MI/STEMI, unstables) that require constant ALS intervention on scene/transport.....you cannot justify requiring the ALS provider for every service to have a B.S. to handle those few calls

In regards to algorithm and protocol based care, there is no point where a patient is "tied to one protocol". You treat based on any protocol that applies to your patient.

Example given, my patient had a syncopal episode due to ventricular dysrhythmia, and now has an isolated extremity fracture. I will treat based on ACLS/cardiac dysrhythmia, extremity trauma, and pain management protocols. I will use the treatment options I need from each protocol, but may not utilize certain components. This requires conscious thought to be in the best interest of the patient and is not cookbook medicine by any stretch.

 

[MICT]

I will continue to disagree. We have paramedic programmes that are less than a thousand hours total and require absolutely no formal (college) education. Moving to mandate a four year degree as entry into practice at this point is rather silly when we do not even have a two year degree or curriculum as an established standard.

I suspect mandating an AAS would be an uphill battle, let alone a four year degree for paramedics. I appreciate your enthusiasm; however, we must be pragmatic in our approach. Perhaps, a four year degree can be discussed at a later date?

Without any real experience, I cannot comment on the UK model. I worked with South African B-tech medics who were four year qualified paramedics and they delivered very good care IMHO.

This is the first time I've ever heard of someone arguing AGAINST raising educational standards, so I'm a little dumbfounded. Exactly how can you justify paramedics being held to the highest standards? Is it unreasonable to expect the people who provide emergency medical care in the prehospital setting to have more years of formal education behind them than the McDonalds manager?

It seems like there is this huge outcry against the poor educational standards currently in place in EMS, so I can't really understand why anyone who recognized this unfortunate truth would be against increasing them. And even if educational standards weren't already poor, we should always strive to increase them.

Licensure should (and I hope will) become the universal credential level for a paramedic, instead of having some states certify and some states license.

I agree with that.

I have agree to paseo on the entry level paramedic requirements. Switching to a required B.S. for paramedics would throw the entire system into chaos. Take into consideration how call volume is divided. 75% of calls are BLS and require no paramedic intervention. 15-20% of calls are medium priority ALS, patients receiving D50, minor-moderate traumas, stable/responsive to treatment. There are very few critical care calls (resp/cardiac arrest or imminent, major trauma, MI/STEMI, unstables) that require constant ALS intervention on scene/transport.....you cannot justify requiring the ALS provider for every service to have a B.S. to handle those few calls

Why not? The majority of ER visits are BS, yet we require a physician to have all the years of formal education that they do to manage those patients. Furthermore, since the studies indicate that ALS is overused, there seems to be a lack of educational direction guiding ALS providers in when to treat versus when not to. If paramedics are not treating patients appropriately as a whole, we ought to conclude there is a single underlying cause and that is poor educational standards.

In regards to algorithm and protocol based care, there is no point where a patient is "tied to one protocol". You treat based on any protocol that applies to your patient.

All of medicine is algorithm and protocol based care. Everyone has their protocols that they follow, from paramedics and nurses to doctors in the ER. Chest pain comes in, doctor knows exactly what tests he has to order before he even sees the patient. It's that kind of standardization that has allowed us to single out the best practices and do away with those that are not beneficial. However, that's a good point that you bring up, because paramedics in general DO try too hard to follow their cookbook medical schemes. The problem is that you can't force a patient into a protocol, but all too often paramedics try to. Trying to equate the ideal paramedic to one who simply follows his protocol to the letter without any thought process or decision making on his or her side is exactly the kind of mentality that shows how desperately paramedic education needs to be augmented. Protocol is a guide to directing patient care, it should never be the deciding force in how paramedics treat their patients.

Example given, my patient had a syncopal episode due to ventricular dysrhythmia, and now has an isolated extremity fracture. I will treat based on ACLS/cardiac dysrhythmia, extremity trauma, and pain management protocols. I will use the treatment options I need from each protocol, but may not utilize certain components. This requires conscious thought to be in the best interest of the patient and is not cookbook medicine by any stretch.

Exactly. Summing up paramedic care to protocol is the exact opposite of what's needed right now. We need independent practitioners capable of making decisions in the best interests in their patients, and to do that we must empower them with real university education so that "when in doubt", we are still making clinically sound decisions instead of simply trying to fit the patient into one protocol.

 

[Paseo Del Norte]

Perhaps you have take me out of context? I am arguing for improving said standards, but moving all the way to a four year degree when we still have 700 hour medic mills operating and no requirement for a two year degree is a bit unrealistic IMHO.

 

[MICT]

Perhaps you have take me out of context? I am arguing for improving said standards, but moving all the way to a four year degree when we still have 700 hour medic mills operating and no requirement for a two year degree is a bit unrealistic IMHO.

I don't disagree that it will be a challenge, but I don't think it's unrealistic or impossible. What it will require is a push from the entire EMS community to demand that the NREMT raises their educational standards.

 

[Paseo Del Norte]

I don't disagree that it will be a challenge, but I don't think it's unrealistic or impossible. What it will require is a push from the entire EMS community to demand that the NREMT raises their educational standards.

The NREMT does not produce educational standards, they test to the standards. The DOT actually creates the curriculum. Unfortunately, the new national standard SOP that is starting to be implemented does not mandate any degree, only that a course be accredited.

Again, this illustrates where EMS is at this point, no where near being able to accept a four year degree as entry into practice. Also, we have fire departments making much of the policy decisions for EMS in the United States. This includes the direction of education. In fact, a fire department for a major city in my area of the country just created an in house paramedic programme that is four months long. All the firefighters can go in and get stamped with a disco patch in a few months, and hit the streets as a fire medic. This course happens to be accredited.

With this kind of stuff going on, we are nowhere near being able to mandate a four year degree. If we could push for a two year degree and nationwide licensure like nurses, then the paramedic would be on equal footing with nurses and at least have equal bargaining power when it comes to home care, working in the facility as a licensed provider (not an unlicensed assistive provider) and providing more advanced triage and assessment decisions. Once this is well established and the paramedic is firmly established as an allied health professional like an RRT, then perhaps we will be in a position to consider a four year degree.

 

[deleted6669]

Some county fire acadmies even include medic certification as part of their programs so every firefighter is a medic....I'm not a big fan of the concept....

 

[EMS5]

The purpose of EMS is to provide acute care to a patient that can benefit from the immediate treatment a paramedic can provide. We are not nor have we ever been utilized as a definitive care option. Our job is to treat any life threatening issues, and then less life threatening issues based on our assessment, and provide transport to a facility that is capable of providing DEFINITIVE care. In the emergency department, many "BLS" complaints may be triaged to mid-level providers.

Please also take into consideration the technology we have available in the field. We have 3 and 12 lead ECG, SpO2, MetHemoglobin, CO, BP, glucose, and ETCO2 as our primary diagnostic technology (plus physical assessment). We do not have available radiology, labs, POC urinalysis, or advanced monitoring that is available within the emergency department.

There isn't much more that a physician can offer in a field that a paramedic can't.

The protocols are developed based on the experience and success when utilized in the emergency departments and based on field trials. The protocols will often cover the best interest of the patient. That said, I (nor most other providers) will not have an issue deviating from protocols as long as we can justify it being in the best interest of the patient.

The main point I was making to begin with is that switching a 1-2 year certificate program into a 4 year B.S. program will throw off the system. Many current EMT-B's and firefighters will not want to commit 4 years of their lives to school. There is already a shortage of EMS providers, with the baby boomer generation the shortage will be maintained and switching to a 4 year credential will create an even larger shortage. Should educational standards be raised? All for it. Make the course more intense, and an AAS. Not a 4 year.

 

[EMS5]

Some county fire acadmies even include medic certification as part of their programs so every firefighter is a medic....I'm not a big fan of the concept....

We have something of the sort locally. The course consists of ACLS, advanced airway, IV, and a couple other meds just to start working a patient until the medic unit or another ALS provider arrives on scene

 

[MICT]

The NREMT does not produce educational standards, they test to the standards. The DOT actually creates the curriculum. Unfortunately, the new national standard SOP that is starting to be implemented does not mandate any degree, only that a course be accredited.

Thanks for correcting me. And yes, that is unfortunate.

Again, this illustrates where EMS is at this point, no where near being able to accept a four year degree as entry into practice.

It is a result of our own making. We, the EMS providers, have the ability to change that; however it will take a unified body working for increased educational standards. Focusing on the problem doesn't bring about a solution; it only guides it.

Also, we have fire departments making much of the policy decisions for EMS in the United States. This includes the direction of education. In fact, a fire department for a major city in my area of the country just created an in house paramedic programme that is four months long. All the firefighters can go in and get stamped with a disco patch in a few months, and hit the streets as a fire medic. This course happens to be accredited.

Is that even possible with the required hours? Well, I suppose I'll trust you on it; though I'm not sure how they could do that. All the same, it's an unfortunate shame that so much say is vested in a group whose primary focus is not emergency medicine. This is just another reason why we must fight against programs like these and decry them publically.

With this kind of stuff going on, we are nowhere near being able to mandate a four year degree. If we could push for a two year degree and nationwide licensure like nurses, then the paramedic would be on equal footing with nurses and at least have equal bargaining power when it comes to home care, working in the facility as a licensed provider (not an unlicensed assistive provider) and providing more advanced triage and assessment decisions. Once this is well established and the paramedic is firmly established as an allied health professional like an RRT, then perhaps we will be in a position to consider a four year degree.

I agree that a two year degree is better, but not that it should stop there. There's no reason why the path to excellence should be a graded response; except that shooting for the real goal from the get go will meet more resistence than giving in to those who want the educational standards to remain low.

The purpose of EMS is to provide acute care to a patient that can benefit from the immediate treatment a paramedic can provide. We are not nor have we ever been utilized as a definitive care option. Our job is to treat any life threatening issues, and then less life threatening issues based on our assessment, and provide transport to a facility that is capable of providing DEFINITIVE care. In the emergency department, many "BLS" complaints may be triaged to mid-level providers.

EMS HAS been used as a treat without transport option, and increasingly in roles that provide definitive treatment where possible. Increasingly in the U.K. and in other foreign EMS models the paramedic's role is expanding to provide out of hospital care in a Mobile Health Services fashion to reduce congestion and costs in the ER.

Please also take into consideration the technology we have available in the field. We have 3 and 12 lead ECG, SpO2, MetHemoglobin, CO, BP, glucose, and ETCO2 as our primary diagnostic technology (plus physical assessment). We do not have available radiology, labs, POC urinalysis, or advanced monitoring that is available within the emergency department.

There are new technologies that are arising every day that may provide further evaluation for out of hospital providers. Things like air blood gas testing, urinalysis and abdominal ultrasound. Also, in the U.K. model non-acute patients can have bloodwork drawn and taken to the hospital to be checked without transporting the patient.

There isn't much more that a physician can offer in a field that a paramedic can't.

I don't disagree with you. However, a physician has much more education behind his assessment; which is something that, I believe, is the most powerful and important tool a paramedic can offer. It's not our skills, it's our knowledge that defines us.

The protocols are developed based on the experience and success when utilized in the emergency departments and based on field trials. The protocols will often cover the best interest of the patient. That said, I (nor most other providers) will not have an issue deviating from protocols as long as we can justify it being in the best interest of the patient.

Good for you! I applaud you, that's exactly the kind of mentality we should all have.

The main point I was making to begin with is that switching a 1-2 year certificate program into a 4 year B.S. program will throw off the system. Many current EMT-B's and firefighters will not want to commit 4 years of their lives to school. There is already a shortage of EMS providers, with the baby boomer generation the shortage will be maintained and switching to a 4 year credential will create an even larger shortage. Should educational standards be raised? All for it. Make the course more intense, and an AAS. Not a 4 year.

I don't disagree with you on any part of that. However, this should be a time when we ask ourselves do we want quantity or quality? An AAS is nice, I'm fortunate to be in one of the few states that requires it in order to become a paramedic; however it's no substitute for a four year degree.

 

[EMS5]

Yes there are a few conditions where we treat and release, mostly (perhaps with the exception of diabetics) patients that would survive or be able to seek non-emergent transportation to the emergency department. The cases where we provide true definitive care for an acute condition are few and far between.

Yes, I am aware of the growing advent of portable blood gas, UA, US, and now even portable labs that can analyze critical electroyte and hemoglobin levels. Because of the price and less than widespread usage these devices, I did not include them as part of our readily available repertoire. The U.K. isn't the only place that obtains blood samples in the field. If I have time I draw blood for cardiac enzymes in chest pain patients. I believe this may even be a registry test item.

Even with the advanced assessment a physician can offer, is there anything they are going to pick up in their assessment that is going to alter the course of treatment? They may get a heads up as to what they would like to do with the patient at the hospital, however they will rarely find anything in their assessment to treat in the field that the paramedic wouldn't find in their assessment.

 

[docB]

A lot of this is impacted by the EMS paradox which is that the areas that need the higher trained people with better equipment are always the rural, underfunded agencies. The downtown agencies get the grants and the funding to have all the classes and the toys and they have short transport times.

We've talked about this issue before.

If we're talking about instituting advanced care medics with additional educational requirements, especially if we're talking about years of additional schooling and degrees we need to think about where these people would work and how we could possible pay for them. What would such an advanced medic get paid? Will you put them on rigs with special duties on on fly cars? Do they get positioned in downtown, suburban or rural areas? If you put them in rural areas how do they stay sharp? If these supermedics are zooming around doing all the hot calls how does everyone else stay sharp?

 

[EMS5]

I could see them receiving competitive pay compared to their clinical counterparts (resp therapists, BSN's) or even near PA level depending on the amount of education and experience.

In my hypothetical world I would have the system:
BLS and ALS transport vehicles
ALS chase units with the "supermedics" placed strategically based on demographics in areas where the greatest number of critical patients are likely to be at any given time.

These providers can offer an expanded set of assessment and treatment options (the exact scope of which someone else can delve into), especially suburban/rural settings. Dual ALS on all critical care patients, that way the supermedics aren't hogging skills and procedures from the transport medics.

In rural areas where critical patients may not be regular enough to maintain a satisfactory level of proficiency, I am a big fan of clinical training. ED/OR to learn approaches to RSI, ICU to learn management of a patient who is crumping or post ROSC, ED to learn maintain patient assessment/management skills while being precepted by a physician. No specific logistics on hours or anything, but some food for thought.

 

[deleted6669]

We have something of the sort locally. The course consists of ACLS, advanced airway, IV, and a couple other meds just to start working a patient until the medic unit or another ALS provider arrives on scene

the program I am thinking of puts a full nremt-p curriculum inside the fire academy, not just an emt-intermediate scope as you describe above. what you get is a lot of guys forced to be medics who really don't want to be so they do just enough to get by...yeah, that's what I want, C+ medics responding to my house....."atropine, adenosine, amiodarone...it's one of em, let's just try em all...."

 

[EMS5]

the program I am thinking of puts a full nremt-p curriculum inside the fire academy, not just an emt-intermediate scope as you describe above. what you get is a lot of guys forced to be medics who really don't want to be so they do just enough to get by...yeah, that's what I want, C+ medics responding to my house....."atropine, adenosine, amiodarone...it's one of em, let's just try em all...."

That's insane. We do have an issue here with a lot of guys who are irritated because the amount of time they spend on the medic > time on the engine. The all-to-common gripe is that "we are FIREFIGHTER/paramedics, not just paramedics".

The drug thing brings a sadistically funny story to mind...we had a full code at a nursing home, no DNR present. I was doing compressions/bagging while another paramedic ran the code. The medic gave epi x 2 and atropine for a brady PEA inside, took the pt to the unit, pt was still PEA, paramedic says lets work it...we worked it until we arrived at the ED (called on arrival by doc)
Total drugs: 4 epi, 2 atropine, 1 calcium, 1 bicarb, and another epi and first lido were sitting on the bench about to be opened when we pulled up.
Eeny meeny miny moe, which drug before the tag on the toe?

 

[ArkansasRanger]

I don't think requiring medics to have a four year degree is a good idea for several reasons. Note, I have a degree and am no longer active in EMS, and I never worked a day as a medic prior to getting my bachelor's.

1. It doesn't make economic sense. They'll want more money in the long run which most EMS agencies won't or can't provide, and the only way to provide that would be to increase their fees and rates. Then there's the issue of billing in EMS.

2. Paramedics are still Emergency Medical Technicians in most places. Technicians generally don't fall in line with the occupations requiring bachelor's degrees.

3. Some people simply don't want to go to college for a myriad of reasons. I'd say the majority of EMS providers fall into that category. If they wanted to go to college they would, and then they'd probably move into another line of work with the burn out rate being what it is in EMS.

The algorithmic approach to problem solving mates well with the level of education and work of a technician. Being a paramedic involves knowing "medical stuff" which is grounded in biology, chemistry, and physics. Most EMS providers unfortunately don't have the background to fully understand, retain, and implement such knowledge. Case in point, I was at a workshop with a medic from another agency once, and he, in front of the class, referred to bacteria as "tiny little bugs that eat stuff and cause diseases."

It'd be great if they knew it all as well as a PA or MD or any other letters, but their increased education comes at a higher cost. I don't even fully agree that RNs all need bachelor's degrees, and I'm very sure that NPs don't need doctorates.

 

[ArkansasRanger]

the program I am thinking of puts a full nremt-p curriculum inside the fire academy, not just an emt-intermediate scope as you describe above. what you get is a lot of guys forced to be medics who really don't want to be so they do just enough to get by...yeah, that's what I want, C+ medics responding to my house....."atropine, adenosine, amiodarone...it's one of em, let's just try em all...."

This reminds me of a fire captain / medic / ACLS instructor. He said in a group medic students only (no nurses or docs) "Ah, the hell with infusion rates. Just squirt a little lidocaine in there. Wait a while. Squirt a little more. They'll be alright."

 

[EMS5]

This reminds me of a fire captain / medic / ACLS instructor. He said in a group medic students only (no nurses or docs) "Ah, the hell with infusion rates. Just squirt a little lidocaine in there. Wait a while. Squirt a little more. They'll be alright."

That's great...I remember our emergency cardiology/ACLS lab... the instructor started the morning off by saying: "you do not run a code by giving one gold box, one purple box, another gold box, oh **** shock, pink box etc"

Still, running a code, (especially if there's a basic on the truck who doesn't ride often) I'll often ask for colors instead of drugs

 

[COMedic2Doc]

The algorithmic approach to problem solving mates well with the level of education and work of a technician. Being a paramedic involves knowing "medical stuff" which is grounded in biology, chemistry, and physics. Most EMS providers unfortunately don't have the background to fully understand, retain, and implement such knowledge. Case in point, I was at a workshop with a medic from another agency once, and he, in front of the class, referred to bacteria as "tiny little bugs that eat stuff and cause diseases."

Definitely agree. This would not only make the system extremely burdensome on either a private ambulance company or government's budget, but many current providers would lose interest and we'd be in worse shape than we are already. You mean codes aren't run by the color of the box? I thought for sure that was part of the next ACLS algorhythm!!