Steps in Professionalizing EMS

[Melclin]

This is great, however if I was going to institue true education. I would have only one level, one test nationwide and be done with it, do we really need three levels?

In this economy what do you do with the billion providers already in use.? If this plan was introduced.

They up-skill just like they did here and are doing in New Zealand.

Funny thing is that if you look back on the history of the Melbourne ambulance services under various names, their level of education was always a selling point to the public, and most of the big changes have come because governments used up-skilling the Ambulance providers as election promises and they seem to prove very popular. I would have thought this would occur to Americans of all people to be a good way to encourage raising the education standards.

 

[MedicSqrl]

EMT or Paramedic is simple and simple is usually the best option.

 

[ExpatMedic0]

For all the aussies, new zeland crew and U.S. people who live in different areas.
United states pop 303,824,646 (July 2008 est.) Oz pop 20,600,856 (July 2008 est.)

population aside, overall you guys appear to have better EMS system but you talk awfully poor about our EMS system a lot of the time.
I am not sure if your aware of this but some states within the united states (including mine) Require an AAS degree which takes 3 years to accomplish and is extremely similar to your 4 year degree. I also work with many paramedics with associate and bachelor degrees. Also our scope of practice is larger than yours in many areas. Medical control (asking the doctor) is hardly every required in many areas. RSI Is standard practice with no MRH in my state and many others.

On the contrast other parts of the U.S. only require 600 hours of training. So it really just depends on your state... To judge the entire country is not accurate

 

[VentMedic]

I am not sure if your aware of this but some states within the united states (including mine) Require an AAS degree which takes 3 years to accomplish and is extremely similar to your 4 year degree.

On the contrast other parts of the U.S. only require 600 hours of training. So it really just depends on your state... To judge the entire country is not accurate

AAS degree similar to a 4 year degree? Not even close.

So far only Oregon and maybe one other midwest state requires a 2 year degree. I believe you also stated Oregon still allows you to practice as a probationary Paramedic until you finish your degree. If that is the case then the two year degree is not even required for entry. There are also 48 other states that have an entry education of 600 - 1000 hours of training with no college education required with many FDs and ambulance services doing their own training without being accredited by CoAEMSP.

On the contrast other parts of the U.S. only require 600 hours of training. So it really just depends on your state... To judge the entire country is not accurate [/quote]

The U.S. also has over 50 different EMS "certs" and some states use different names for "Paramedic". Different states also use different certifying exams. We have the most fragmented EMS education of any civilized country in the world.

We also have very few requirements when it comes to education for instructors in EMS here in the U.S. which gives us the minimually educated and trained teaching those who have slightly less education and training.

I also work with many paramedics with associate and bachelor degrees. Also our scope of practice is larger than yours in many areas.

I would hope that the Paramedics in your state have the Associates as required for Oregon and not all have given an IOU to the state promising to get the degree. Those that have Bachelors may also not have the degree in anything EMS. As well, other healthcare professions are already requiring a degree higher in their discipline since they believe their 2 year degree entry is rather pathetic. That includes the RN and the RRT.

Also our scope of practice is larger than yours in many areas. Medical control (asking the doctor) is hardly every required in many areas. RSI Is standard practice with no MRH in my state and many others.

Your state is also not that large. However, the stats on your success rates have not be widely published yet if at all. Other states have had varying success with RSI since intubation rates in some parts of the U.S. suck to where that skill is going to the wayside for alternative airways such as the King or Combitube. Other areas have totally eliminated pedi intubation.

I wouldn't brag about all the systems here in the U.S. that just have "skills" and very little education to back up the why and hows especially in a country where many of the providers argue against education. You yourself agrued against it in your earlier posts and thought it was stupid for Oregon to make you get a degree.

 

[Melclin]

For all the aussies, new zeland crew and U.S. people who live in different areas.
United states pop 303,824,646 (July 2008 est.) Oz pop 20,600,856 (July 2008 est.)

population aside, overall you guys appear to have better EMS system but you talk awfully poor about our EMS system a lot of the time.
I am not sure if your aware of this but some states within the united states (including mine) Require an AAS degree which takes 3 years to accomplish and is extremely similar to your 4 year degree. I also work with many paramedics with associate and bachelor degrees. Also our scope of practice is larger than yours in many areas. Medical control (asking the doctor) is hardly every required in many areas. RSI Is standard practice with no MRH in my state and many others.

On the contrast other parts of the U.S. only require 600 hours of training. So it really just depends on your state... To judge the entire country is not accurate

Given a higher population density, you would think that would afford America the money and need for higher education standards.

You make a fair point. I am aware that some have a better education that typically gets talked about. The high standard of conversation that sometimes occurs hear and more often on other forums is a testament to that. Remember though, that our bachelors is not for the ALS level, its for ILS. Our 'paramedics' are more ILS than anything. You have to achieve extra experience and show particular aptitude (in theory ) to go to the ALS graduate studies (typical called Intensive Care Paramedics). But nonetheless, I take your point. You and other educated paramedics (although they are far too few) should not take my, or other's, generalizations about the US to be about you.

 

[VentMedic]

Remember though, that our bachelors is not for the ALS level, its for ILS. Our 'paramedics' are more ILS than anything. You have to achieve extra experience and show particular aptitude (in theory ) to go to the ALS graduate studies (typical called Intensive Care Paramedics). But nonetheless, I take your point. You and other educated paramedics (although they are far too few) should not take my, or other's, generalizations about the US to be about you.

There are only about 5 states that do have a level for a critical care paramedic, again with varying requirements, while other will take whatever.

In the U.S., a "critical care Paramedic" can also wear that title by as little as 2 hours of training in the back room of an ambulance station to a whopping 80 hour class by an independent certifying agency. They can also buy a book on how to pass the FP-C or CCP and take a test without any prior experience.

 

[Melclin]

There are only about 5 states that do have a level for a critical care paramedic, again with varying requirements, while other will take whatever.

In the U.S., a "critical care Paramedic" can also wear that title by as little as 2 hours of training in the back room of an ambulance station to a whopping 80 hour class by an independent certifying agency. They can also buy a book on how to pass the FP-C or CCP and take a test without any prior experience.

There's probably room for misunderstanding here. Our "Intensive Care Paramedics" (ICPs) are not the same as your "Critical Care Paramedics" (CCPs)as I understand it. My understanding of CCPs is that they are predominantly involved in CC transfers not 911 response, which is not the case for our ICPs. ICPs here, are simply the ALS backup, in the same sense as an EMT-P, while our 'paramedics' are our 'basics' but practice at somewhere between the ILS and ALS levels. CC transfer here is less common and done predominantly by Flight Intensive Care medics (which is further post graduate study on top of the Intensive Care graduate diploma) and/or physician based retrieval teams.

 

[VentMedic]

There's probably room for misunderstanding here. Our "Intensive Care Paramedics" (ICPs) are not the same as your "Critical Care Paramedics" (CCPs)as I understand it. My understanding of CCPs is that they are predominantly involved in CC transfers not 911 response, which is not the case for our ICPs. ICPs here, are simply the ALS backup, in the same sense as an EMT-P, while our 'paramedics' are our 'basics' but practice at somewhere between the ILS and ALS levels. CC transfer here is less common and done predominantly by Flight Intensive Care medics (which is further post graduate study on top of the Intensive Care graduate diploma) and/or physician based retrieval teams.

And you have again made my point. While we do have flight teams with Paramedics who have some additional training, it is common for what I previously described to be "adequate". An RN (or two) is commonly paired with the Paramedic or used instead of Paramedics.

 

[EMTinNEPA]

Australia has MICA (mobile intensive care ambulance) and we have Intensive Care Paramedic (ALS).

Anyway, heres what you need to do:

- National certifying exam
- National scope of practice from the 21st century
- National union (look at how powerful the Teamsters, PBA and IAFF are)
- No more of this "Firefighter/Paramedic" crap
- Proper funding, so what if people pay a buck extra on thier house tax?
- National levels (I think EMT/A EMT/Paramedic wording works OK)
- National education standards
- Proper education; lets be realistic here, two semesters BLS, AAS degree for ILS and a Bachelors Degree for ALS all based at a college or university none of this tech mill back alley education.

Scope of practice could be something like this

BLS
- O2
- Entonox
- Nitrates SL
- Aspirin PO
- Ventolin nebules
- Glucagon IM
- Adrenaline auto for severe asthma, anaphylaxis and croup
- Anti emetic PO
- Obtain 3 and 12 lead
- ? IM Nalxone?
- Supraglottic airway
- CPAP

ILS
- Manual defib
- Cardioversion
- IV fluid
- Laryngoscopy and McGills forceps
- Adrenaline IV for severe asthma, anaphylaxis, croup, cardiac arrest
- Anti arrythmatic IV for cardiac arrest
- Opiod antagonist IM IN IV
- Benzo IM IN for seizures
- IV analgesia
- Anti emetic IV
- ? steriod IV for severe asthma, anaphylaxis
- ? pacing
- ? IO access

ALS
- Intubation
- RSI if approved locally
- Thrombolysis if approved locally
- Atropine IV
- Further IV analgesia eg ketamine, etomidate
- Pacing
- ? frusemide IV
- ? dopamine IV
- Anti arrythmatic for besides cardiac arrest

Forgive me for asking this, but why even have an ILS level? Or better yet, why even have a BLS level? The stepping stone process we have with Basic vs. Medic is already silly, why have a middle level and especially why give them all the capabilities you want with less education than a paramedic?

Registered Paramedic...
- O2
- Entonox
- Nitrates SL
- Aspirin PO
- Ventolin nebules
- Glucagon IM
- Adrenaline auto for severe asthma, anaphylaxis and croup
- Anti emetic PO
- Obtain 3 and 12 lead
- IM Nalxone
- Supraglottic airway
- CPAP
- Manual defib
- Cardioversion
- IV fluid
- McGills forceps
- Adrenaline IV for severe asthma, anaphylaxis, croup, cardiac arrest
- Anti emetic IV

Critical Care Paramedic...
- Laryngoscopy
- Anti arrythmatic IV for cardiac arrest
- Opioid antagonist IM IN IV
- Benzo IM IN for seizures
- IV analgesia
- Anti emetic IV
- steriod IV for severe asthma, anaphylaxis
- pacing
- IO access
- Laryngoscopy and Endotracheal Intubation
- RSI (TRUE RSI with succinylcholine, not poor man's RSI with fentanyl and midazolam)
- Thrombolytics (for STEMIs only)
- Atropine IV
- Further IV analgesia eg ketamine, etomidate
- Pacing
- furosemide IV
- dopamine IV
- Anti arrythmatic for besides cardiac arrest
- Intra-aortic balloon pumps
- Ventilators
- Opioid drips for continuous sedation
- Pericardiocentisis

I like the idea of thrombolytics in the pre-hospital setting, but there are inherent problems... for instance how do you differentiate between thrombotic and hemorrhagic CVA in the field?

And if you're going to give naloxone to basics, why in IM form? Intra-nasal atomizer would be much safer, easier, and quicker, especially with an EMT's education. They're already giving narcan atomizers to cops in some part of the country, why not EMTs?

 

[Melclin]

Forgive me for asking this, but why even have an ILS level? Or better yet, why even have a BLS level? The stepping stone process we have with Basic vs. Medic is already silly, why have a middle level and especially why give them all the capabilities you want with less education than a paramedic?

This scope is suggested, I think with, much better education for all levels in mind.

Registered Paramedic...
- O2
- Entonox
- Nitrates SL
- Aspirin PO
- Ventolin nebules
- Glucagon IM
- Adrenaline auto for severe asthma, anaphylaxis and croup
- Anti emetic PO
- Obtain 3 and 12 lead
- IM Nalxone
- Supraglottic airway
- CPAP
- Manual defib
- Cardioversion How are you supposed to cardiovert without sedatives?
- IV fluid
- McGills forceps
- Adrenaline IV for severe asthma, anaphylaxis, croup, cardiac arrest
- Anti emetic IV
No D10%?
Critical Care Paramedic...
- Laryngoscopy Why not give this to an RP?
- Anti arrythmatic IV for cardiac arrest
- Opioid antagonist IM IN IV
- Benzo IM IN for seizures
- IV analgesia What not give this to an RP? IV analgesia seems to be treated like plutonium in some American EMS culture.
- Anti emetic IV
- steriod IV for severe asthma, anaphylaxis
- pacing
- IO access Why not give this to the RP as well. Its not exactly complicated. If soldiers can be taught to use them (certain types obviously), then so can a medical professional
- Laryngoscopy and Endotracheal Intubation
- RSI (TRUE RSI with succinylcholine, not poor man's RSI with fentanyl and midazolam)
- Thrombolytics (for STEMIs only)
- Atropine IV
- Further IV analgesia eg ketamine, etomidate
- Pacing
- furosemide IV
- dopamine IV
- Anti arrythmatic for besides cardiac arrest
- Intra-aortic balloon pumps
- Ventilators
- Opioid drips for continuous sedation
- Pericardiocentisis

I like the idea of thrombolytics in the pre-hospital setting, but there are inherent problems... for instance how do you differentiate between thrombotic and hemorrhagic CVA in the field? Its for AMI, not stroke.

And if you're going to give naloxone to basics, why in IM form? Intra-nasal atomizer would be much safer, easier, and quicker, especially with an EMT's education. They're already giving narcan atomizers to cops in some part of the country, why not EMTs?
IN narcan and midaz is not common here, and many of the medics I've talked too don't even know about it. Just one of those odd things I suppose, but its a good idea

10 character

 

[MrBrown]

In a country with three hundred million people and a zillion different ways that services are delivered and funded for the intermin anyway you need some sort of achievable level for volunteers (BLS).

The future may see the demise of volunteer systems beyond community first response type arrangements but that's not gonna come any time soon by my reckoning.

New Zealand has adopted a consensus decision to upskill our volunteers to a sensible BLS level and all paid staff to ILS Paramedic or Intensive Care level; it should be noted that paid staff undertake about 80% of the national workload so while technically we have three levels in reality you're far more likely to see one of two (Paramedic or Intensive Care) at your cardiac arrest or broken finger.

 

[MrBrown]

I hate to toot my own horn but New Zealand is currently changing how we do business to build a professional Paramedic workforce of the future (weird Darth Vader style sounds here)

Basic Life Support ("Ambulance Technician")
~ One year Diploma in Ambulance Practice

- Oropharyngeal airway
- Laryngeal mask airway
- Nasopharyngeal airway
- Advisory defibrillation
- Entonox
- Oxygen
- Paracetamol PO
- Aspirin PO
- Glucagon IM
- GTN SL
- Anti emetic PO
- Salbutamol neb
- PEEP valves
- Combat application torniquet

Intermediate Life Support ("Paramedic")
Three year Bachelor of Health Science (Paramedic)

- IV cannulation
- 0.9% NaCl IV
- 10% glucose IV
- Manual defibrillation
- Cardioversion
- Adrenaline IV (cardiac arrest)
- Amiodarone IV (cardiac arrest)
- Adrenaline IM, neb
- Zofran IV
- Morphine IM, IV
- Naloxone IM, IV, IN

Select services (probably end up going national)
- Ceftriaxone IM
- Clopidogrel PO

Advanced Life Support ("Intensive Care Paramedic")
Post Graduate Certificate in Intensive Care Paramedicine

- Chest decompression
- Cricothyroid puncture
- Endotracheal intubation
- Laryngoscopy
- IO cannulation
- Transcutaneous pacing
- Adrenaline IV
- Amiodarone IV
- Atropine IV
- Frusemide IV
- Ketamine IM, IV
- Midazolam IM, IV, IN
- Vecurnoum and suxamethonium IV (selected ALS Officers)

Select services (probably eventually national)
- CPAP
- Salbutamol IV
- Tenecteplase IV
- Hydrocortisone IV
- Heparin IV
- Magnesium Sulfate IV

Would not suprise me if ILS get midaz IM for seizures at some point too

 

[Melclin]

New Zealand has adopted a consensus decision to upskill our volunteers to a sensible BLS level and all paid staff to ILS Paramedic or Intensive Care level; it should be noted that paid staff undertake about 80% of the national workload so while technically we have three levels in reality you're far more likely to see one of two (Paramedic or Intensive Care) at your cardiac arrest or broken finger.

Thats the same deal we have (I know we've discussed it already but for the rest of the thread -->). While the majority of the state services are at the Paramedic (ILS) and MICA Paramedic (ALS) level, in a lot of rural areas we have a part time paid level called Ambulance Community Officer (ACO) who have comparatively little training and strict BLS protocols. They make up the numbers on rural trucks when they're short of the ILS guys, but they also respond by themselves, with the exception being that they are supposed to have ILS backup on all jobs, although in practice that doesn't happen. Many are studying to become paramedics themselves and wish to assist their community while they are working to become fully qualified ILS Paramedics. Ideally this would not be the case, but rural Australia is such that it is necessary - we have twenty two million people on a chunk of land roughly the same size of America.

This is separate and in addition to the Community Emergency Response Teams who are entirely volunteer rural First Responders, they can't transport and they are only dispatched for life threatening conditions.

 

[DV_EMT]

it should be as such:

-EMT-B (or just EMT so that you dont have confusion between roman numeral 1 and I for intermediate)
-EMT-I (which would include the I)
Paramedic
CC-P
and FL-P

or just change EMT-B and EMT-I to EMT 1 and EMT 2

 

[JPINFV]

Well... it looks like California is going to try to switch over to EMT, AEMT, Paramedic in July. http://www.emsa.ca.gov/about/EMT2010_Overview.asp

 

[grich242]

The goal is to eventully have the NR as the national exam for all states. When that happens it would not be necessary to use "national registry" in front of the level. Other health care professionals all take one test recognized throughout the U.S. and do not use the name of their testing agency in their titles. EMS is just different because some states still use their own tests.

Our State will at last I heard will be dropping the national registry in the future and not require accreditation. And from what I understand it was mostly the colleges who were against accreditation, as well as some discrepancies with the national cirriculum.

 

[alphatrauma]

Our State will at last I heard will be dropping the national registry in the future and not require accreditation. And from what I understand it was mostly the colleges who were against accreditation, as well as some discrepancies with the national cirriculum.

I'm sorry, maybe I'm missing something... is this supposed to be a good thing?

 

[grich242]

I'm sorry, maybe I'm missing something... is this supposed to be a good thing?

I'm still on the fence on this one... I have heard good arguments on both sides and I fully understand the need for more education in this field and am not opposed to it at all.... However in a state that had reciprocity with some 40 states at one time the national registry was brought in as a cost cutting measure at the state level.. According to the colleges that were opposed the economy sucks here and they are not interested in another accreditation with the fees etc, as the quote I was given was about $15k to start as well as the year of paperwork. Oddly a lot of the so called medic mills are currently seeking accreditation. There is also the issue of scope of practice in some areas where the national standard would be lower than what we have here. Most of those to the best of my knowledge are little things like our mfr's backboard where in the new national cirriculum the supposedly do not.. but thats from the state official, I have not looked it up my self. but I was told there are a few in each level.

 

[VentMedic]

Our State will at last I heard will be dropping the national registry in the future and not require accreditation. And from what I understand it was mostly the colleges who were against accreditation, as well as some discrepancies with the national cirriculum.

The colleges already had accreditation capabilities because they teach other healthcare programs that required most of the things on the list which are with CAAHEP and CoAEMSP is under that heading.

Michigan will quickly reconsider their decision to drop the NREMT when they discover how costly it is to do their own testing.

If you have not looked up the new levels, you should do so before you spread rumors you may not be able to back up.

I had posted the links in the education section but they are easily found on the internet.

 

[EMTinNEPA]

This scope is suggested, I think with, much better education for all levels in mind.
Fair enough.

How are you supposed to cardiovert without sedatives?
Again, fair enough. Didn't think that one through.

Why not give this to an RP?
Because if they aren't going to intubate, there isn't much point to giving them laryngoscopy. Unless they're removing a foreign object from the airway.

What not give this to an RP? IV analgesia seems to be treated like plutonium in some American EMS culture.
Because if you give RPs everything, why even have CCP? I would propose one level and one scope of practice, but then who will do dialysis runs and discharges? You think somebody with the abilities I proposed for CCP is going to want to do that? RP, in my proposed arrangement, would basically be EMT-Basic with MUCH more education and more skills so that when assisting CCPs they'll be able to do more than sit on their hands.

Why not give this to the RP as well. Its not exactly complicated. If soldiers can be taught to use them (certain types obviously), then so can a medical professional.
Depends on what they teach RPs. There are certain risks that go along with IO access... damaging the growth plates in children, infection...

Its for AMI, not stroke.
http://emergency-medicine.jwatch.org/cgi/content/full/2008/924/1...
Besides, even if it is paramedic-approved just for STEMIs, you know there's going to be some cowboy out there who uses it for a stroke that turns out to be hemorrhagic and kills somebody and thrombolysis will be taken right back off of us.

IN narcan and midaz is not common here, and many of the medics I've talked too don't even know about it. Just one of those odd things I suppose, but its a good idea
We carry atomizers as well as narcan and versed. The atomizer is a nice tool when IV access is difficult or time-consuming to the point of being detrimental to the patient.

Responses in bold.