Advanced care options in EMS?

[Siggy]

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'd argue that it doesn't really matter what you call a piece of paper that is, in practice, a license. Quick question (I'll answer it below). Are physicians licensed or certified in California?

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

I'll counter this by saying that the number that just needs BLS is irrelevant. The vast majority of those calls don't need BLS either, just a ride. What I will argue, though, is that one of the problems with US EMS is that the base level (EMT) is vastly undereducated, thus requiring a tiny scope of practice. Ideally the base response level should be able to treat most of the 911 calls, including most of the calls that require interventions at currently the paramedic level. Ideally, the base level would be able to give (for example, including, but not limited to) D50, manually cardiovert/defibrillate, nitro, CPAP, blind airways, etc. The bread and butter, low risk paramedic level interventions. The upper tier provider would be able to provide the high risk, high benefit interventions that have been shown to be at, or approaching, an unacceptable level of risk when everyone and their cousin in a paramedic and only get the opportunity to provide the intervention on blue moons in years ending with 5. Things like ET intubation (including RSI, but lower provider population means more indepth training and less 1 trick laryngoscope ponies, chest decompressions, surgical crics, so on and so forth. The current system where the majority of the providers can essentially provide a ride, and not much else (oh, yea, the magical miracle drug of oxygen that cures everything) is a crime. It's similarly a crime when fire departments dispatch an engine, truck, and ambulance and everyone who shows up is a paramedic. There's a reason why, for example, not all physicians intubate.

Ideally, the base level would be an AS and the upper level will be a BS. Protocols would be structured as ideal treatment plans with paramedics expected to deviate as needed (they are supposed to be professionals, not technicians, after all). Online medical control used as a check for only the highest risk procedures and if a paramedic needs to consult a physicians (imagine the difference in mindset if it was "online medical consult" instead of "online medical control")

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.

Why do you even need a protocol to begin with though? If the patient presents with X, Y, and Z and the proper treatment for X, Y, and Z is 1, 2, and 3, shouldn't 1, 2, and 3 be given because it's the right treatment, not because the protocol said so?


To answer my question about California licensing or certifying physicians, I present a quote from California's Business and Professions Code.

"2040. The terms "license" and "certificate" as used in this chapter
are deemed to be synonomous."
-Chapter 5: Medicine. Article 2: General Provisions.
http://www.leginfo.ca.gov/cgi-bin/displaycode?section=bpc&group=02001-03000&file=2030-2041

A few more quotes from that same chapter and article.

"2039. All certificates issued by the board shall state the extent
and character of the practice which is permitted."

"2041. The term "licensee" as used in this chapter means the holder
of a physician's and surgeon's certificate or doctor of podiatric
medicine's certificate, as the case may be, who is engaged in the
professional practice authorized by the certificate under the
jurisdiction of the appropriate board."

If the people writing the laws can't figure out the difference between certificate and license, then does it really matter? For all intents and purposes, paramedics and EMTs are granted the legal privilege to engage in acts that are otherwise restricted by law, provided that the acts are done in accordance with the law governing said privilege with the state being able to take action up to, and including, revoking said privilege. This is a license, plain and simple.

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[Siggy]

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.

1 and 2. Then paramedics need to quit complaining about just being technicians and how their professionals following a technicians cookbook. Additionally in terms of 1, lobby to make reimbursment better. As a Dr. ExMedic stated on JEMS connect, the problem with that is most paramedics don't care about lobbying anything because they're either doing it as a hobby, don't care, or working 2 jobs (to give a bit of background, this was in a thread asking why physicians and not paramedics were taking the lead in increasing EMS vehicle standards).

3. I'm really starting to not dig medical school. Is there any physician mill programs accredited in all 50 states that lets me cut out the useless crap and get in and out in 2 years? See argument about professional vs technician.

[snark]If nurses didn't have BSNs, then they couldn't complain that TV shows aren't showing all the important nursing interventions, like defibrillation.

http://www.nursingadvocacy.org/faq/dramatic.html[/snark]

 

[ArkansasRanger]

I agree with you that beggers can't be choosers. If you want change then cause it to happen. Of all the EMS types I've met only one was an advocate for the occupation, profession, or whatever we're calling it here. I was the guy in it for a hobby, lol.

I don't know. Perhaps the civic mindedness is limited to the more educated variety. I doubt that, but more education generally allows for jobs with which one can better control their hours and working conditions thus have time to advocate. Just a thought. Can't have one without the other though I suppose.

1 and 2. Then paramedics need to quit complaining about just being technicians and how their professionals following a technicians cookbook. Additionally in terms of 1, lobby to make reimbursment better. As a Dr. ExMedic stated on JEMS connect, the problem with that is most paramedics don't care about lobbying anything because they're either doing it as a hobby, don't care, or working 2 jobs (to give a bit of background, this was in a thread asking why physicians and not paramedics were taking the lead in increasing EMS vehicle standards).

3. I'm really starting to not dig medical school. Is there any physician mill programs accredited in all 50 states that lets me cut out the useless crap and get in and out in 2 years? See argument about professional vs technician.

[snark]If nurses didn't have BSNs, then they couldn't complain that TV shows aren't showing all the important nursing interventions, like defibrillation.

http://www.nursingadvocacy.org/faq/dramatic.html[/snark]

 

[ArkansasRanger]

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

I'm red-green color blind. I have to read my crayons and my acls drugs.

 

[EMS5]

Sorry the quotes didn't go through for whatever reason

I'd argue that it doesn't really matter what you call a piece of paper that is, in practice, a license. Quick question (I'll answer it below). Are physicians licensed or certified in California?

California? You couldn't pick a weirder state to compare to all the others. They are also the only ones that still use wooden fire ladders. My point was that certification is just that, proof that you have completed the courses/labs/practicals and meet the educational standards for doing X. I support licensure as the official term for credentialing because it implies that this person has the authority to practice in the field. What if we gave out driving certificates? Same theory.


[/QUOTE] I'll counter this by saying that the number that just needs BLS is irrelevant. The vast majority of those calls don't need BLS either, just a ride. What I will argue, though, is that one of the problems with US EMS is that the base level (EMT) is vastly undereducated, thus requiring a tiny scope of practice. [/QUOTE]

The standard these days is either P/B rigs or dual dispatch rigs with an engine company. There is no need to have two advanced life support providers on board. The basic is more than capable of handling the patients that just need rides to the hospital.

[/QUOTE] Ideally the base response level should be able to treat most of the 911 calls, including most of the calls that require interventions at currently the paramedic level. Ideally, the base level would be able to give (for example, including, but not limited to) D50, manually cardiovert/defibrillate, nitro, CPAP, blind airways, etc. The bread and butter, low risk paramedic level interventions. [/QUOTE]

D50 is a no go. The risk that goes with extravasation if you don't secure a large vein is too high. For a provider level that doesn't routinely practice intravenous therapy, obtaining the 18ga needed in a diabetic may be difficult. This is the reasons many services equip basics with glucagon for unresponsive diabetics.

Cardioversion and defibrillation? This requires ECG interpretation skills. If you are doing defibrillation, a paramedic needs to be present because at this point you are running a code.

CPAP and blind airways are already a BLS skill in some places. Each of the skills you mentioned that has practical applications for a lower level provider without requiring the full paramedic training is already in use to some extent. In reality, a paramedic will be present on any of the patients that would benefit from these therapies, so I can't justify a super-basic with that much of an expanded scope.

[/QUOTE] The upper tier provider would be able to provide the high risk, high benefit interventions that have been shown to be at, or approaching, an unacceptable level of risk when everyone and their cousin in a paramedic and only get the opportunity to provide the intervention on blue moons in years ending with 5. Things like ET intubation (including RSI, but lower provider population means more indepth training and less 1 trick laryngoscope ponies, chest decompressions, surgical crics, so on and so forth. [/QUOTE]

Nothing you have mentioned will change the provider population. You may even decrease the BLS providers (because of the additional training that would be required) or INCREASE the number of paramedics (because of the lesser difference in training compared to before). Intubation is still and will be something paramedics don't practice regularly enough outside the hospital to be unquestionable. RSI should be left to a very few specially trained medics.

[/QUOTE]The current system where the majority of the providers can essentially provide a ride, and not much else (oh, yea, the magical miracle drug of oxygen that cures everything) is a crime. It's similarly a crime when fire departments dispatch an engine, truck, and ambulance and everyone who shows up is a paramedic. There's a reason why, for example, not all physicians intubate. [/QUOTE]

This is a social and system issue, not an individual provider issue. Do I agree with a 3 piece response on all EMS calls? No. Do I think certain calls should be pre-screened and have medical assist respond with the rig? Absolutely.

[/QUOTE]Ideally, the base level would be an AS and the upper level will be a BS. Protocols would be structured as ideal treatment plans with paramedics expected to deviate as needed (they are supposed to be professionals, not technicians, after all). Online medical control used as a check for only the highest risk procedures and if a paramedic needs to consult a physicians (imagine the difference in mindset if it was "online medical consult" instead of "online medical control") [/QUOTE]

I've addressed the whole protocol/standards of care in an earlier post

 

[Siggy]

Sorry the quotes didn't go through for whatever reason




California? You couldn't pick a weirder state to compare to all the others. They are also the only ones that still use wooden fire ladders. My point was that certification is just that, proof that you have completed the courses/labs/practicals and meet the educational standards for doing X. I support licensure as the official term for credentialing because it implies that this person has the authority to practice in the field. What if we gave out driving certificates? Same theory.

Does the legislatures mandate wooden fire ladders? As far as the bottom half, I agree that's why it should be a license, however if the people who write the laws can't understand the difference, then there's more important things to be concerned about than that specific piece of nomenclature.

I'll counter this by saying that the number that just needs BLS is irrelevant. The vast majority of those calls don't need BLS either, just a ride. What I will argue, though, is that one of the problems with US EMS is that the base level (EMT) is vastly undereducated, thus requiring a tiny scope of practice.

The standard these days is either P/B rigs or dual dispatch rigs with an engine company. There is no need to have two advanced life support providers on board. The basic is more than capable of handling the patients that just need rides to the hospital.

I'll agree that the basic is more than capable of handling a patient who has received a paramedic level assessment, which is not ensured in many parts of the country, including parts of Southern California. EMS is supposed to be more than a ride, and a ride is essentially all that EMTs provide.

Ideally the base response level should be able to treat most of the 911 calls, including most of the calls that require interventions at currently the paramedic level. Ideally, the base level would be able to give (for example, including, but not limited to) D50, manually cardiovert/defibrillate, nitro, CPAP, blind airways, etc. The bread and butter, low risk paramedic level interventions.

D50 is a no go. The risk that goes with extravasation if you don't secure a large vein is too high. For a provider level that doesn't routinely practice intravenous therapy, obtaining the 18ga needed in a diabetic may be difficult. This is the reasons many services equip basics with glucagon for unresponsive diabetics.

Cardioversion and defibrillation? This requires ECG interpretation skills. If you are doing defibrillation, a paramedic needs to be present because at this point you are running a code.

CPAP and blind airways are already a BLS skill in some places. Each of the skills you mentioned that has practical applications for a lower level provider without requiring the full paramedic training is already in use to some extent. In reality, a paramedic will be present on any of the patients that would benefit from these therapies, so I can't justify a super-basic with that much of an expanded scope.[/quote]

How can some provinces in Canada justify it with the Primary Care Paramedic as the base level then? In reality, a huge problem is that there are, arguably, too many paramedics for the high risk/low utilization procedures. See the paramedic intubation studies as a perfect example. So the question is, in part, how do we limit the number of people who do the high risk/low utilization interventions without decreasing access to the most common interventions? We either raise the base level (and please don't take this to mean I support EMTs gone wild with 200 hours of training) to a level able to provide the vast majority of care to the people who actually need care, introduce and support a strong intermediate level that becomes the primary "ALS" provider, or start removing the parts of paramedic scope that has been shown to be too dangerous given the sheer number of paramedics currently operating.

The 'strong intermediate' level is already in place, to an extent, in Wake County with the Advance Practice Paramedic system where the APPs either attend to prevention house calls or specific emergencies, thus limiting some procedures basically to the APPs. This essentially makes the paramedics there an intermediate provider between the APPs and the EMTs. The long term effects would be very interesting to see (overall numbers and specific providers numbers especially).

The upper tier provider would be able to provide the high risk, high benefit interventions that have been shown to be at, or approaching, an unacceptable level of risk when everyone and their cousin in a paramedic and only get the opportunity to provide the intervention on blue moons in years ending with 5. Things like ET intubation (including RSI, but lower provider population means more indepth training and less 1 trick laryngoscope ponies, chest decompressions, surgical crics, so on and so forth.

Nothing you have mentioned will change the provider population. You may even decrease the BLS providers (because of the additional training that would be required) or INCREASE the number of paramedics (because of the lesser difference in training compared to before). Intubation is still and will be something paramedics don't practice regularly enough outside the hospital to be unquestionable. RSI should be left to a very few specially trained medics.
[/quote]
In terms of "Why won't the number increase with less of a difference in training?" Why are there physicians assistants then? A few more years of school and they could have been a physician, yet there they are? Is there another solution that doesn't involve a complete retooling of our levels that solves the high risk/low utilization (e.g. intubations) problem?

 

[EMS5]

Its my funny-funny haha about California...they still use wooden fire ladders and everything causes cancer in lab rats in the state of California (completely irrelevant to subject matter)

In most cases, the patient does not even require a paramedic level assessment. I think one of the most important things when you are a basic (as with the PA/MD) is knowing when to ask for help.

In Canada, PCP's are the equivalent of basics in the states. As with basics, certain provinces allow them to perform a few ALS level skills and medications.

You obviously haven't watched the video on the WC EMS website. The APP program they started does not give anyone an expanded skillset or reduce the scope of practice of rig medics. They merely respond to critical calls to offer an additional set of experienced eyes and a fresh mind in the management of that patient. The rig medics still do their own procedures, and the APP may jump in and begin additional procedures when needed.

PA's spend 4-6 years in school at a minimum with no required post-grad training, MD's spend 8 years in school plus at least 3 years of residency, and often have to taken out massive loans.

The solution if you ask me is more clinical training, con ed, and safer alternatives.