# Community Paramedicine, The next step?



## ExpatMedic0 (Jan 28, 2013)

Community Paramedics make the clinical decision to treat, release, and refer with out transport. Many of you maybe aware of the "Community Paramedic" concept, which is already being used in Australia, the UK, and even Qatar. It has been slowly surfacing as a concept In the United States the past few years and gaining more ground. So much that the NAEMT has dedicated its own section of there website to it. http://www.naemt.org/about_ems/CommunityParamedicine.aspx

What does this mean for us as Advanced Pre-hospital providers? Will we(EMS) get this right? Could this be the saving grace for those of us who love EMS and want to take the next step while staying a pseudo clinician? Will the new U.S. Patient Protection and Affordable Care Act (PPACA) help us achieve this?

Its a big possibility but there is also the big possibility for this to fail and become just another "badge upgrade class" like PHTLS, AMLS, ACLS, PALS, PEPP, ect ect.

I hope that the U.S. will model its system off other western countries that already use this concept with success.

In the U.S. we are the red head step children of almost everything we are affiliated with such as healthcare and emergency responders. The two do not seem to mix very well, and EMS has an identity crisis regarding the two. However, what if we affiliated with a new allie, Public Health? 

We are already on the front line of Public Health, particularly for Health Disparities( I.E. vulnerable populations). Often we maybe the majority of health care contact many of these people receive in some systems.


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## Veneficus (Jan 28, 2013)

I think that "community paramedicine" is the only way forward for EMS in the US.

I think because of its role as the first contact for vulnerable populations it is actually serving the need that PAs and NPs claimed they would be servicing but actually don't. 

I do not think the legislation mentioned will help. Mostly because EMS has not advanced itself educationally at the current time to be realistically included. 

After many years I am convinced EMS has nothing to do with public safety. It was just a duty grudgingly accepted by public safety agencies. (Both Police and Fire depending on the area)

EMS could serve a very significant public health role. But I think in order to do that it will have to disengage itself from control of Emergency Medicine physicians who have a financial incentive to keep it how it is now.

As for the few US programs today, I think they are testing the water befoe the plunge so to speak. To my knowledge, not one of the places that have instituted it has experienced failure. 

As I understand, Wake County is compiling actual statistics on its effectiveness and I hope Mr. Kirkwood will share those with me after they are complete.


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## Rialaigh (Jan 28, 2013)

Veneficus said:


> I think that "community paramedicine" is the only way forward for EMS in the US.
> 
> I think because of its role as the first contact for vulnerable populations it is actually serving the need that PAs and NPs claimed they would be servicing but actually don't.
> 
> ...



I am very interested in this and I believe Mr. Kirkwood is excellent at what he does and there will be great success with this program. I live a couple hours south of Wake County and have heard nothing but great things about how progressive and research oriented their service is. They have currently implemented double gloving for CPR and not stopping compressions to shock, you just keep right on pumping. This was tested at great length in cadaver labs and has been implemented and I am hoping they will find some success with this coupled with "pit crew" CPR that they are currently running. 

I am very hopeful for this study and if you hear anything please let me know and keep us in the loop


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## Veneficus (Jan 28, 2013)

Rialaigh said:


> I am very interested in this and I believe Mr. Kirkwood is excellent at what he does and there will be great success with this program. I live a couple hours south of Wake County and have heard nothing but great things about how progressive and research oriented their service is. They have currently implemented double gloving for CPR and not stopping compressions to shock, you just keep right on pumping. This was tested at great length in cadaver labs and has been implemented and I am hoping they will find some success with this coupled with "pit crew" CPR that they are currently running.
> 
> I am very hopeful for this study and if you hear anything please let me know and keep us in the loop



I just spoke with him and he said it is not completed but told me that Medstar in Ft. Worth have some good numbers for their program.


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## Shishkabob (Jan 28, 2013)

Veneficus said:


> I just spoke with him and he said it is not completed but told me that Medstar in Ft. Worth have some good numbers for their program.



Yes we do.  If you'd like, I can get you in contact with any number of the people that head it. 


We have our APPs (Advanced Practice Paramedics) that were the initial wave of community paramedicine, and recently 'hired' several "CHP" (Community Health Program) Paramedics to auguments the APPs in the normal day-to-day home visits so the APPs can do the more critical calls (Cardiac arrests, etc) and critical care transfers. 



> Since its inception, MedStar's CHP has saved more than $7.4 million in emergency room charges, and reduced 9-1-1 use by these patients by 86.2 percent in 12 months post-enrollment, saving $1.6 million in EMS charges.


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## EpiEMS (Jan 28, 2013)

Linuss said:


> Yes we do.  If you'd like, I can get you in contact with any number of the people that head it.
> 
> 
> We have our APPs (Advanced Practice Paramedics) that were the initial wave of community paramedicine, and recently 'hired' several "CHP" (Community Health Program) Paramedics to auguments the APPs in the normal day-to-day home visits so the APPs can do the more critical calls (Cardiac arrests, etc) and critical care transfers.



What's the protocol and SoP difference between the two? Are CHPs APPs with a focus on more GP-type medicine?


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## Shishkabob (Jan 28, 2013)

To be honest, the CHP-medics are brand new as we just hired a couple from within and I don't know much more beyond what was included in the internal job posting.



Our current protocols are split in to levels 1-6, each level a corresponding provider level.  (Protocols are changing this month, doing away with the levels)

1: EMT
2: Intermediate
3: Paramedic (New to the system, can't have their own truck, basically an intermediate with a few more things)
4:  Lead Paramedic (Has their own truck, full working Paramedic, most Paramedics are this level)
5:  Paramedic (Has a few more things such as RSI)
6: APP, Advanced Practice Paramedic.  They have even more open to them.



Without knowing for sure, I'm betting the CHPs are still level 4 or 5, but they are used for the general home visits and checking out the patients.  I don't believe they have the refusal capability of the APPs, and doubt they have the advanced protocols, otherwise they'd be the APPs instead of a separate branch.


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## EpiEMS (Jan 28, 2013)

What patient population is the target for the CHP program?


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## Shishkabob (Jan 28, 2013)

Depends, really.  CHFers are a big part, followed by psych and general system abusers (terms not mutually exclusive)

This is a good link to read up on the basics that was put in for a government grant.
http://www.innovations.ahrq.gov/content.aspx?id=3343&tab=1



I actually referred someone a couple weeks ago because I transported them several times in several weeks and saw their call log was basically every couple of days, always complaining about the same thing.  They got enrolled and we've transported them a lot less, but they are a difficult case because they are non-complaint with discharge orders, and call back because they keep doing the same thing, causing the same complaint... Simple fix they refuse to do.


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## EpiEMS (Jan 28, 2013)

Linuss, that's a fascinating program. Sounds like it does an excellent job (especially compared to the baseline).


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## ExpatMedic0 (Jan 28, 2013)

Linus what area of Texas? Is there any kind of degree requirement or specialized training for this pilot program?


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## Shishkabob (Jan 28, 2013)

Fort Worth, Texas (North part of Texas, next to Dallas)


The last job opening stated having gone through a CCT class and 2 years as a Lead Paramedic with MedStar.  They then do a 16 day program going further in-depth with the CHP and critical care.


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## ExpatMedic0 (Jan 28, 2013)

Nice, Texas has the "licensed Paramedic" level which requires an AAS or above right? I am really surprised they are not requiring that. 1 step at a time I suppose. 





Linuss said:


> Fort Worth, Texas (North part of Texas, next to Dallas)
> 
> 
> The last job opening stated having gone through a CCT class and 2 years as a Lead Paramedic with MedStar.  They then do a 16 day program going further in-depth with the CHP and critical care.


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## Shishkabob (Jan 28, 2013)

Yes, Texas' LP is either an AS in EMS or a bachelors in anything.  It was initially intended to replace some nursing sports in trauma rooms but you can guess the hissy-fit the nurses threw around.  As such, LPs haven't really taken off like it should have, but it's still going.


Most of the APPs I know have an AAS at minimum... some are going to medical school as we speak.  



Doesn't hurt that our medical director started as a Paramedic here, got his RN, then got his DO and is back.


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## EpiEMS (Jan 28, 2013)

A tad off topic...Do LPs make more than EMT-Ps in Texas?


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## Shishkabob (Jan 28, 2013)

EpiEMS said:


> A tad off topic...Do LPs make more than EMT-Ps in Texas?



Not at any employer I've ever seen, which is partially why there hasn't been a big influx.  What comes first, education or pay?  You'll have someone on both sides arguing their side.



Without an immediate incentive of increased pay, I don't see why most people would push for it.  (Right or wrong or indifferent)


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## Summit (Jan 28, 2013)

Lerner B, Shah MN, Fernandez AR *(2008). Do EMS Providers Think They Should Participate in Disease Prevention?* 
Poster presentation at 2008 annual meeting of the National Association of EMS Physicians.
The objective of this study is to determine EMS providers’ opinions regarding participation in disease prevention initiatives. Eighty-one percent (95% CI: 80.5 -81.6) of EMS providers re-registering in 2006 believed that they should participate in disease prevention programs and 28.8% (95% CI: 28.2-29.5) of respondents reported actually having provided prevention services. *Those who had a graduate degree were the most likely to have provided prevention services (40%, p<0.001), as were those who had worked in EMS for more than 21 years (41%, p<0.001).*

As a side note, community health nursing is one of the few nursing specialties that absolutely requires a BSN minimum.


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## Veneficus (Jan 28, 2013)

Summit said:


> Lerner B, Shah MN, Fernandez AR *(2008). Do EMS Providers Think They Should Participate in Disease Prevention?*
> Poster presentation at 2008 annual meeting of the National Association of EMS Physicians.
> The objective of this study is to determine EMS providers’ opinions regarding participation in disease prevention initiatives. Eighty-one percent (95% CI: 80.5 -81.6) of EMS providers re-registering in 2006 believed that they should participate in disease prevention programs and 28.8% (95% CI: 28.2-29.5) of respondents reported actually having provided prevention services. *Those who had a graduate degree were the most likely to have provided prevention services (40%, p<0.001), as were those who had worked in EMS for more than 21 years (41%, p<0.001).*
> 
> As a side note, community health nursing is one of the few nursing specialties that absolutely requires a BSN minimum.



I'm a 41%er!!!


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## Shishkabob (Jan 28, 2013)

No, you're just old.


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## Veneficus (Jan 28, 2013)

Linuss said:


> No, you're just old.



I managed to live this long, so don't mess with me


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## EpiEMS (Jan 28, 2013)

Linuss said:


> Not at any employer I've ever seen, which is partially why there hasn't been a big influx.  What comes first, education or pay?  You'll have someone on both sides arguing their side.
> 
> Without an immediate incentive of increased pay, I don't see why most people would push for it.  (Right or wrong or indifferent)



What ED spots were the LPs supposed to take over for the RNs?


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## Hunter (Jan 28, 2013)

This is great, Linuss. Few questions that popped up.

How are the crews staffed? Is it the AAP alone during the house visits?

If the AAP isn't alone with either an EMT-B, a regular paramedic, or even another AAP, do they transport if say they arrive to a house call and the patient has a serious condition? Or do you call 911 for another unit?


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## Veneficus (Jan 28, 2013)

EpiEMS said:


> What ED spots were the LPs supposed to take over for the RNs?



If you didn't know, up until sometime in the early 80s many US emergency departments did not utilize nurses, they had "ED techs."

The nursing lobby got very active with nurse to patient ratios before ED RNs were universal. I know some old techs working today, but they're almost at retirement age.

Hospitals still see the need for these techs and can capitalize on the initial EMT and Medic certifications as proof of training in various procedures, instead of teaching them exclusively in house. 

As I am aware, most of these positions have  shifted to operate under the nursing staff as opposed to directly for the medical staff, but I wouldn't doubt somewhere there is a hold out. 

Some countries outside the US, that do not have specific nurse to patient ratios have found considerable benefit in having only 1 or 2 nurses in the ED and using paramedics almost exclusively.


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## Shishkabob (Jan 28, 2013)

Hunter said:


> How are the crews staffed? Is it the AAP alone during the house visits?


  Typically by themselves, yes.  I don't know what's happening with the new CHP medics, but I've seen a few APP trucks with dual people lately.  Maybe a 'getting them up to speed' type of thing?  



> If the AAP isn't alone with either an EMT-B, a regular paramedic, or even another AAP, do they transport if say they arrive to a house call and the patient has a serious condition? Or do you call 911 for another unit?


They drive an SUV or van with no transport capabilities, so if they decide the patient needs transport, they call for an ambulance and transfer care to the ambulance Paramedic.  I've yet to go L&S to an APP initiated transport.



EpiEMS said:


> What ED spots were the LPs supposed to take over for the RNs?



From what I understand, equal to RNs, hence their hissy-fit.



Veneficus said:


> I managed to live this long, so don't mess with me



That's just because you haven't run in to me yet.  h34r:


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## Veneficus (Jan 28, 2013)

Linuss said:


> That's just because you haven't run in to me yet.  h34r:



I thought Linuss was the name of the cereal I had for breakfast?


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## VFlutter (Jan 28, 2013)

Linuss said:


> From what I understand, equal to RNs, hence their hissy-fit.



Are LPs allowed to initiate blood products, legally witness consent, or provide patient education? 

Those are they only things I can think of off the top of my head that may be grey areas in practice.


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## Shishkabob (Jan 28, 2013)

Chase said:


> Are LPs allowed to initiate blood products, legally witness consent, or provide patient education?
> 
> Those are they only things I can think of off the top of my head that may be grey areas in practice.



Paramedics have no legally defined scope of practice in Texas.  We can do anything and everything, which is why EMS in Texas is as progressive and aggressive as it is. 


So, yes.  CCT trucks start blood all the time.  Consent wise, technically Paramedics obtain consent and not just witness it (if we're talking about the same nursing definition?).  And I educate every patient I come in to contact with that requires education (whether they want it or not   )


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## EpiEMS (Jan 28, 2013)

Linuss said:


> From what I understand, equal to RNs, hence their hissy-fit.



Ok, makes sense. Still below PAs and NPs, I imagine? That is, no treat-and-release, but more to assist the MD in management of patients?



Veneficus said:


> If you didn't know, up until sometime in the early 80s many US emergency departments did not utilize nurses, they had "ED techs."
> 
> The nursing lobby got very active with nurse to patient ratios before ED RNs were universal. I know some old techs working today, but they're almost at retirement age.
> 
> ...



This is fascinating! I was unaware of the exclusive use of techs -- I guess I thought the nursing lobby was always as powerful as it is now 
I was in an ED in NH, and they used medics at parity with RNs, except with broader authority to manage patients on their own, which was quite novel to me.


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## ExpatMedic0 (Jan 28, 2013)

Linus you should push for LP to be a requirement for those community medic positions, and some how increase the pay wage, make the weather in Texas not so hot, and then... Maybe Ill come say hi ;-)


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## EpiEMS (Jan 28, 2013)

schulz said:


> Linus you should push for LP to be a requirement for those community medic positions, and some how increase the pay wage, make the weather in Texas not so hot, and then... Maybe Ill come say hi ;-)



If there was good money in it, I'd love to live in Austin or Houston do my medic...and do some grad school at UT or Rice (respectively). Any idea how Austin EMS is?


Regarding the APP and CHP programs, I've only found a couple sets of protocols.

Anybody have any others than Wake and MedStar?


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## ExpatMedic0 (Jan 29, 2013)

I was "shopping around" with graduate school ideas and came across this one. I think this could be modified to fit the Community Paramedic education on top of a Paramedic certification and health or science degree. Maybe if you took some elements from this and some elements from something like a PA program then combined them with an experienced paramedic

http://www.oregonmph.org/content/primary-health-care-health-disparities


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## ExpatMedic0 (Jan 29, 2013)

When I say modify it I mean you could remove some of the policy making aspects but keep the many of the other elements, combined that some mid level provider type course work for direct patient care like a PA program for example. It should be noted the one pilot program I saw is only requiring a 200 hour community college course. I do not believe this would be suitable for the long term if this is to succeed.


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## ExpatMedic0 (Jan 29, 2013)

One last thing. My last company was Aussie. They where sponsoring us to complete this masters degree http://www.ecu.edu.au/future-students/our-courses/overview?id=I58

You could choose Community Paramedic or Critical Care


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## Summit (Jan 30, 2013)

schulz said:


> One last thing. My last company was Aussie. They where sponsoring us to complete this masters degree http://www.ecu.edu.au/future-students/our-courses/overview?id=I58
> 
> You could choose Community Paramedic or Critical Care



I kinda want to move to Australia now...


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## ExpatMedic0 (Jan 30, 2013)

Summit said:


> I kinda want to move to Australia now...



Ya, After working with those guys, I love the Aussies. I especially love what they have done with there EMS system. I think if the United States can look at Australia more we might have a chance at really making this succeed.


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## RocketMedic (Jan 30, 2013)

Everything I've heard about Austin-Travis County EMS is that it's just like EMSA with double-strength Kool-aid.


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## shfd739 (Jan 30, 2013)

Rocketmedic40 said:


> Everything I've heard about Austin-Travis County EMS is that it's just like EMSA with double-strength Kool-aid.



Nah. Same strength, different flavor


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## Shishkabob (Jan 30, 2013)

schulz said:


> and some how increase the pay wage,


 APPs already get 6-10% more than the next lower provider!  What more do you want?!  



> make the weather in Texas not so hot


  Hey now, it's only 75* today... in January...



Come fly out and do a ride-along with a system truck and an APP car.


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## ExpatMedic0 (Jan 30, 2013)

How close are you to Austin? Is that a spot an outsider can walk into from another agency?


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## WolfmanHarris (Jan 30, 2013)

As part of one of our professional development days we had a update briefing on what's been happening with our Community Paramedicine project where I work. I don't have a rundown of all the various irons in the fire, but I'll share some of the highlights of what's happening or being proposed:

Current programs
- Community Referrals by EMS (CREMS)
      With this program we identify patients who could benefit from referral to the Community Care Access Centre, which is a centralized program for connecting patients to resources. Patient types that fall into this program range from those needing mobility devices or home adaptations for fall arrest, to home visits by a nurse, to mental health resources, to financial help with medical costs, to education, to placement in an LTC facility. We don't have public stats on this program but we do get individual follow-up letters to see how our Pt. did (great positive reinforcement) and I've seen some frequent fliers in the making stop calling after getting better help at home.

- Shelter visits by Paramedics
       Currently three of the area shelters are visited by Paramedics that are outside our usual car count (light duties, community programs etc) and risk assessments and referrals are done for these populations that traditionally only use 911 as their access to healthcare. This program has connected these patients with a family MD, education resources through the hospital, mental health care and other programs. Currently only 4% of patients seen via this program end up directed to 911.


Programs coming in the short term:

- Geriatric Emergency Nurse. Medics are being asked to screen elderly patients for risk factors to tier these patient for a visit from the specialist geriatric emergency nurses as part of their ED stay who will also look at more chronic factors with an eye to decreasing short term return to hospital.

- Nurse Practitioner Response to LTC facility. Currently area hospitals have a Nurse Practitioner team that is set-up to respond to urgent, but not necessarily emergent cases in area LTC facilities in lieu of 911 with the intent to care for the patient in place. Uptake by the LTC's has been limited due to turnover and lack of integration into 911. A partnership with our service and the regional dispatch is proposed to ensure this team is tiered as part of the 911 call and to allow medics to work in partnership with the NP to assess the patient, remain on scene until the NP can arrive (as appropriate), assist with care and then transfer care back to the NP without transport.

- Alternative patient disposition. Four area urgent care centres have agreed in principle to accept transports of moderate acuity patients from EMS. Some area walk-in clinics have agreed in principle to reserve spots each day for referrals by EMS (Pt. self transports to walk-in). This is awaiting Provincial approval and regulatory changes.

Longer term programs:
- Certificate in Community Paramedicine. Starting in September, Centennial College will be offering a 1 year certificate in Community Paramedicine. While services are not yet in a position to fully utilize the skill set being added with this sort of program, the focus on assessment of chronic and subacute patients will be immediately beneficial. How this type of education will be utilized at my service is not yet clear.  http://db2.centennialcollege.ca/ce/certdetail.php?CertificateCode=7191

- Physician Assistant. In principle a local PA program has agreed to hold spots for Paramedics from my service in the program with the goal to train experienced medics to this level. How they will be utilized and a time line for this program is not yet available. Likely a few years still.


It's an extremely exciting time for the profession around here and Community Paramedicine is part of that. My service has embraced this transition with open arms and stakeholders from the EMS Chiefs of Canada, to the Ontario Paramedic Chiefs, to Regional Council, to the Minister of Health and leading position papers on health care in Ontario have shown support for making these changes as part of a larger response to the strain on health care and the aging population.

To me this is not about changing our role as much as recognizing that the patients have dictated what our role needs to be. When people only dialed 911 for immediate emergencies the traditional curriculum made sense, but the patients types have expanded and our education is only geared for about 10% of what we're presented with. The onus is on us to adapt our education to fit the medical need.


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## ExpatMedic0 (Feb 4, 2013)

It looks like you guys are on the right track Wolfman, good to hear.

By the way here is a couple interesting websites to check out 

http://www.ircp.info/

http://www.communityparamedic.org/


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## Carlos Danger (Feb 5, 2013)

In brainstorming for the future of the profession, I would keep in mind a few things: 


Simply admiring the Canadian, Australian, and European models of EMS will do nothing to change things in the US. We need to actually _DO_ something. We have an entirely different model of healthcare and reimbursement than they have over there; their system will not automatically replicate itself here.


Like it or not, it is an absolute joke to even being to discuss "advanced practice" issues when most paramedic programs are still 2-semester vocational programs which utilize textbooks written at a 10th grade reading level and whose only pre-requisites are a GED and a 90-hour EMT course. 

Seriously...you can barely do the pre-reqs a for 2 year nursing program in the amount of time it takes to become a paramedic, and you can graduate paramedic school with fewer clinical hours than an AAS program nursing student does in 1 semester. Whereas NP's and CRNA's with doctorates and hundreds of hours of clinical experience are having to fight in court for the right to do the types of things that paramedics are wanting to do.


In the US, paramedics are generally looked upon by many _(if not most) _physicians as _barely educated technicians_, rather than as professional clinicians.


With the current model of paramedicine in the US being 100% dependent on physicians for approval in everything that we do, we can accomplish nothing - _no sweeping changes at all_ - without the approval of physicians. 


These models and initiative we are discussing _(community paramedicine, acvanced-practice paramedicine)_ will never garner widespread support from physicians, because there is no money in it for them, and nothing to allay their liability. 


 Physicians will not willingly cede control of what goes on in the prehospital arena. They may appear uninterested now, but as soon as someone else starts making money in EMS, believe me, the doctors will assert their authority. Just ask the CRNA's.


 Corollary to number 6: Even those professionals who _are_ indisputably classified as clinicians constantly battle with physician groups over issues related to autonomy, scope of practice, and billing. Generally this relates to advanced-practiced nurses _(NP's, CRNA's, CNM's)_, as PA's, RA's, and AA's are inherently physician-dependent models of practice. Just ask the CRNA's.


If you are really willing to work to advance the paramedic profession, it is probably much easier and more effective to effect change as a PA or NP who has earned the respect of their physician colleagues and learned the ins-and-outs of healthcare politics than it is to do so as a paramedic. *Because unfortunately, no matter how well educated and experienced a paramedic you are, you are still "just a paramedic".*


I don't mean to be all doom-and-gloom. EMS is full of very smart, motivated clinicians who really want to effect positive change. And that is perhaps the most important factor.

We just have to be realistic about what we are up against: market forces and  physician interests. 

For anyone who really wants to effect change in EMS, my suggestions are these:


Become an ED PA or NP. Maintain your state EMT-P card, and keep some active involvement with EMS. (_alternatively, earn a BS degree at a minimum - a MS or PhD is better - and be active in education, professional organizations, and lobbying) _ 


Don't be afraid to piss off the physicians. This is a little easier to get away with as an NP than as a PA.


Learn how to lobby at the state level.


 We have to learn how to do research, or at least how to interpret and "exploit" _(for lack of a better term)_ research that supports our vision.


Push for much higher educational standards for paramedics in your state.


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## VFlutter (Feb 5, 2013)

old school said:


> [*] Physicians will not willingly cede control of what goes on in the prehospital arena. They may appear uninterested now, but as soon as someone else starts making money in EMS, believe me, the doctors will assert their authority. Just ask the CRNA's.
> 
> 
> [*] Corollary to number 6: Even those professionals who _are_ indisputably classified as clinicians constantly battle with physician groups over issues related to autonomy, scope of practice, and billing. Generally this relates to advanced-practiced nurses _(NP's, CRNA's, CNM's)_, as PA's, RA's, and AA's are inherently physician-dependent models of practice. Just ask the CRNA's.



Great points. EMS as a whole could learn a lot about professional advancement from CRNAs who have been fighting a similar battle for years. 

I once heard a MD say that CRNAs are the Paramedics of nursing. Undereducated providers trying to perform advanced procedures and then arguing that they are superior to everyone else. 

Although there are distinct differences I think there are some similarities in how they both will be viewed by Physicians and their respective struggles. 

I am guessing some Emergency Physicians will try to set up something similar to the ACT model and utilize community paramedics to substantially increase their billable patient loads.


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## Carlos Danger (Feb 5, 2013)

Yeah, I don't think there is much parallel at all between paramedics and CRNA's in terms of education, or in comparison to their MD counterparts as far as scope of practice or demonstrated outcomes....

But I don't doubt at all that some doctor said it, and I definitely agree there's a lot that paramedicine can learn from advanced-practiced nursing in general, and nurse anesthesia in particular.


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## medicsb (Feb 5, 2013)

old school said:


> In brainstorming for the future of the profession, I would keep in mind a few things:
> 
> 
> Simply admiring the Canadian, Australian, and European models of EMS will do nothing to change things in the US. We need to actually _DO_ something. We have an entirely different model of healthcare and reimbursement than they have over there; their system will not automatically replicate itself here.
> ...





Lets not get ahead of ourselves here.  These nursing doctorate programs, short of a PhD, are a joke.  In terms of medicine, they're even more of a joke.  BSN to DNP requires a little more than 1000 hours of clinical time, which is about what a 3rd year med student does in 6 months.    



> [*]In the US, paramedics are generally looked upon by many _(if not most) _physicians as _barely educated technicians_, rather than as professional clinicians.



By and large, paramedics/EMS has not quite reached "professional" status nor "clinician" status.  Be that as it may, the physicians who know what a paramedic does do tend have respect for them.  But most physicians, particularly those not in EM know almost nothing about EMS or paramedics.




> [*] Physicians will not willingly cede control of what goes on in the prehospital arena. They may appear uninterested now, but as soon as someone else starts making money in EMS, believe me, the doctors will assert their authority. Just ask the CRNA's.
> 
> [*] Corollary to number 6: Even those professionals who _are_ indisputably classified as clinicians constantly battle with physician groups over issues related to autonomy, scope of practice, and billing. Generally this relates to advanced-practiced nurses _(NP's, CRNA's, CNM's)_, as PA's, RA's, and AA's are inherently physician-dependent models of practice. Just ask the CRNA's.



 

NPs are nowhere near the level of training and education that is obtained by a physician and are a lower level of care and are fought as they should be.  They should have no autonomy - they haven't earned it and do not deserve it.  Though CRNAs have a much more rigorous training program, they are nonetheless inferior in training and education and should not be allowed to touch a single patient with complete autonomy.  

Regardless, I think it is totally fair for any profession to put a stake in the ground and declare a territory as their own.  I only think it appropriate for others to come in when there is an undisputed need.  I don't care to see paramedics in EDs or ICUs functioning as nurses.  That job is for nurses.  I don't care to see NPs or PAs trying to play doctor, when that is the job of a doctor.  I similarly don't care to see PAs or NPs trying to be paramedics.  The goal of APP or community health medics is, in my mind, to deal with patients related to EMS, in terms of prevention (i.e. proactive vs. reactive).  





Chase said:


> I once heard a MD say that CRNAs are the Paramedics of nursing. Undereducated providers trying to perform advanced procedures and then arguing that they are superior to everyone else.



Actually, the MDs assessment doesn't sound to far-fetched.  Maybe almost spot-on in some cases.



> I am guessing some Emergency Physicians will try to set up something similar to the ACT model and utilize community paramedics to substantially increase their billable patient loads.



EPs won't see much benefit from community medics.  It will be hospitalists and specialties whose future reimbursement will depend upon "quality metrics" such as hospitalization, rehospitalization, medication compliance, etc. of their patients.


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## Carlos Danger (Feb 5, 2013)

medicsb said:


> NPs are nowhere near the level of training and education that is obtained by a physician and are a lower level of care and are fought as they should be.



You are completely missing the point.

Regardless of how you feel that an NP's training compares to a physicians, the point is that they have far more training than paramedics, yet still have problems gaining autonomy. 





medicsb said:


> They should have no autonomy - *they haven't earned it and do not deserve it*.  Though CRNAs have a much more rigorous training program, *they are nonetheless inferior in training and education and should not be allowed to touch a single patient with complete autonomy.  *



These are highly subjective and emotional statements with no basis in fact. Rather than continuing to spew ignorance, I would suggest that you review the history of APN's, as well as the literature concerning outcomes between FNP's vs. Family Practice MD's and also between CRNA's and MD's.




medicsb said:


> By and large, paramedics/EMS has not quite reached "professional" status nor "clinician" status. Be that as it may, the physicians who know what a paramedic does do tend have respect for them.



They show you respect because it doesn't cost them anything. But try to get them to support you doing something that they could potentially bill for.....and see how much "respect" they have for paramedics then.



This thread is about the advancement about paramedicine, and how the field can learn from others that have gone before it. 

You sound like just another paramedic who is disgruntled at nurses because they make more money than and have more career opportunities than he does.

If you just want to bash nurses, or debate the educational models of the different types of providers, that's fine..... but start a different discussion.


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## Carlos Danger (Feb 5, 2013)

medicsb said:


> NPs are nowhere near the level of training and education that is obtained by a physician and are a lower level of care and are fought as they should be.  They should have no autonomy - they haven't earned it and do not deserve it.  Though CRNAs have a much more rigorous training program, they are nonetheless inferior in training and education and should not be allowed to touch a single patient with complete autonomy.



Ahhh, I see.....a medical student 

That explains the objectivity, lol.

I guess I'd be cranky too, if I knew I were investing lots of time and money into entering a profession whose model is cost-innefective, at a time when reimbursement dollars are becoming more and more scarce.


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## VFlutter (Feb 5, 2013)

medicsb said:


> NPs are nowhere near the level of training and education that is obtained by a physician and are a lower level of care and are fought as they should be.  They should have no autonomy - they haven't earned it and do not deserve it.  Though CRNAs have a much more rigorous training program, they are nonetheless inferior in training and education and should not be allowed to touch a single patient with complete autonomy.



I am not going to try to argue that NPs should have total autonomy because for the most part I think it is a bad idea and we both know neither of our opinions will change since we both have professional stakes. However, the required physician involvement for many NP and even some PA is so non existent it is laughable.

An example of what I think old school is referring to: ACNPs have at least 6 years of education requiring 2 years of ICU experience. Up until recently Intubation was outside their scope of practice in many states and had to fight tooth and nail for it compared to a skill that is automatically granted to paramedics.


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## Tigger (Feb 5, 2013)

Let's keep things civil and on topic here please.


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## VFlutter (Feb 5, 2013)

Ok, Back on topic. 

It sounds like a great idea if it can be done the right way. I think we can all agree that is going to take more than a 200 hour course like some places are pushing for. I think a PA program with specialty in paramedicine may be a better more feasible alternative.


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## JPINFV (Feb 5, 2013)

old school said:


> [*]In the US, paramedics are generally looked upon by many _(if not most) _physicians as _barely educated technicians_, rather than as professional clinicians.


That's because the large number of <1 year certificate paramedics makes the average paramedic look like a barely educated technician. Don't mistake current location with ideal location. Also you shouldn't care what a pathologist or pediatrician thinks of EMS. 



> [*]With the current model of paramedicine in the US being 100% dependent on physicians for approval in everything that we do, we can accomplish nothing - _no sweeping changes at all_ - without the approval of physicians.


...and with the growth of EMS specialized EM physicians, the number of EMS friendly physicians are going to grow. It's not necessarily an antagonistic situation. 


> [*]These models and initiative we are discussing _(community paramedicine, acvanced-practice paramedicine)_ will never garner widespread support from physicians, because there is no money in it for them, and nothing to allay their liability.


The prior point and this one are at odds with each other. As is the assumption that all physicians are greedy businessmen just looking to earn an extra buck. Sure, we're not going to spend a decade of our lives and half a million dollars in debt to make 50k/year, but most of us aren't Gordon Gekko (Reference: movie: Wall Street. Quote: "Greed is good") either. 



> [*] Physicians will not willingly cede control of what goes on in the prehospital arena. They may appear uninterested now, but as soon as someone else starts making money in EMS, believe me, the doctors will assert their authority. Just ask the CRNA's.


So if intermediates all of a sudden say that they're just like paramedics and should be able to do everything a paramedic does with significantly less education, you'd be fine with it? 


> [*] Corollary to number 6: Even those professionals who _are_ indisputably classified as clinicians constantly battle with physician groups over issues related to autonomy, scope of practice, and billing. Generally this relates to advanced-practiced nurses _(NP's, CRNA's, CNM's)_, as PA's, RA's, and AA's are inherently physician-dependent models of practice. Just ask the CRNA's.


You mean midlevel providers who want only the easy patients, punt anything hard to physicians, and want the same pay, respect, and privilege as physicians? ...and physicians should just roll over and accept it? If I was mean, I'd say that we should set up two systems of healthcare. One ran by physicians (and physician supervised midlevels) and one by autonomous midlevels (who can subsequently pay their own malpractice). When a midlevel poops the bed (and all providers end up pooping the bed, but want to compare a 2 year educated noctor in IM (internal nursing? After all, nursing isn't medicine... according to nurses) practicing independently to a physician who has 4 years of med school and 3 years of IM residency?), they should only be allowed to refer to another midlevel.

The problem with the militant midlevels is that they want all the benefits of being a physician without the struggles or risks (i.e. malpractice) of being a physician. Being a patient advocate also means knowing one's own limitations. The midlevels who want in essence an unrestricted license to practice medicine do not know their own limitations. 







> For anyone who really wants to effect change in EMS, my suggestions are these:
> 
> 
> Become an ED PA or NP. Maintain your state EMT-P card, and keep some active involvement with EMS. (_alternatively, earn a BS degree at a minimum - a MS or PhD is better - and be active in education, professional organizations, and lobbying)_


Why not go to med school if you want to play with the big dogs?


----------



## JPINFV (Feb 5, 2013)

old school said:


> You are completely missing the point.
> 
> Regardless of how you feel that an NP's training compares to a physicians, the point is that they have far more training than paramedics, yet still have problems gaining autonomy.


Because autonomy should be handed out like toys from a Crackerjack box? 




> These are highly subjective and emotional statements with no basis in fact. Rather than continuing to spew ignorance, I would suggest that you review the history of APN's, as well as the literature concerning outcomes between FNP's vs. Family Practice MD's and also between CRNA's and MD's.


You mean ones like this abortion of statistics?
http://www.ncbi.nlm.nih.gov/pubmed/10632281

17 physicians to 7 NPs? Hardly a powerful study, painfully short study period (6 months and 1 year?) and relying on simple statistical significance as a crutch. Where's the relative risk ratio? What about medical signficiance? Oh, look, a 3 point drop in diastolic BP? Heck, that's not even out of the normal margin of error for most blood pressure cuffs (+/-3 mmHg). Can we discuss the the validity of a study which is mostly a survey when it comes to saying that primary care physicians and NPs are equal? 



> They show you respect because it doesn't cost them anything. But try to get them to support you doing something that they could potentially bill for.....and see how much "respect" they have for paramedics then.



By gosh, by golly, how the heck are there even community paramedic programs to begin with! [/sarcasm]





> This thread is about the advancement about paramedicine, and how the field can learn from others that have gone before it.
> 
> You sound like just another paramedic who is disgruntled at nurses because they make more money than and have more career opportunities than he does.
> 
> If you just want to bash nurses, or debate the educational models of the different types of providers, that's fine..... but start a different discussion.



What I heard you say here was, "How dare someone disagree with me and not think that mid levels are the best thing since sliced bread."


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## JPINFV (Feb 5, 2013)

old school said:


> Ahhh, I see.....a medical student



...and what's your background? 





> I guess I'd be cranky too, if I knew I were investing lots of time and money into entering a profession whose model is cost-innefective, at a time when reimbursement dollars are becoming more and more scarce.



Cost-inneffectiveness? Physician pay is about 20% of US healthcare costs in 2010. Now there's a catch here. Physicians don't make 20% of healthcare costs in take home pay. That includes overhead and insurance and supplies and staff. Unless midlevels can fart out malpractice insurance, clinic space, supplies, and support staff (including nursing staff) for their clinics, then they're going to have the same overhead costs as physicians. That makes the amount of the pie representing take home pay significantly less.


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## medicsb (Feb 6, 2013)

old school said:


> You are completely missing the point.
> 
> Regardless of how you feel that an NP's training compares to a physicians, the point is that they have far more training than paramedics, yet still have problems gaining autonomy.



I don't think I missed any point, but, I'll clarify mine:  short of an MD or DO - no one should be allowed complete autonomy to practice medicine - nurse, paramedic, or PA.  I do not think it unreasonable to grant a certain degree of autonomy, but within medicine, the physician is the ultimate authority and should have ultimate control.  



> These are highly subjective and emotional statements with no basis in fact. Rather than continuing to spew ignorance, I would suggest that you review the history of APN's, as well as the literature concerning outcomes between FNP's vs. Family Practice MD's and also between CRNA's and MD's.



I'm familiar with the various studies of dubious quality that the nursing lobby tout.  There vast differences in training quality and quantity is undeniable.  Moving on...



> They show you respect because it doesn't cost them anything. But try to get them to support you doing something that they could potentially bill for.....and see how much "respect" they have for paramedics then.



EMS has long been able to bill for medical care, which hasn't caused physicians to oppose paramedics, especially since paramedics initiate care that could otherwise be initiated by a doc at a hospital for which they'd be able to bill.  I don't think physicians are threatened by "community paramedics", particularly since most of these (all?) of these programs have been initiated by physicians or with strong physician support.  Even in NJ, community paramedics are being considered.  The only folks there I've heard raising objections are nurses.  

And as mentioned previously, there are A LOT of physicians who got their start in EMS.  I do not foresee physicians opposing these programs as currently envisioned.


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## usalsfyre (Feb 6, 2013)

medicsb said:


> Regardless, I think it is totally fair for any profession to put a stake in the ground and declare a territory as their own.


The vast majority of my complaints about nursing relate to this exactly. Micturate in your own sand box.....


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## Carlos Danger (Feb 6, 2013)

*see what I mean? you just proved my point for me.*



medicsb said:


> I'm familiar with the various studies of dubious quality that the nursing lobby tout.


Studies of such "dubious quality" that they have been accepted by CMS, the Institute of Medicine, and many if not most state hospital associations, all which have issued statements or directives arguing for expanded use of APN's "to their fullest potential".

Here's something to chew on: The salaries that anesthesiologists demand are in most cases significantly higher than the revenue that they generate. This means that the large hospitals lose money on every anesthesiologist that they employ. 

CRNA's, on the other hand, can bill for the same amount as MD's, yet are perfectly happy working for HALF what an anesthesiologist requires......now how do you think that's gonna wash out when the Affordable Care Act takes full effect and hospitals get so tight for dollars that they have no choice but to start making really tough decisions about cutting services and looking at who and what is really cost effective?

And if CRNA's are unsafe providers, then explain why their malpractice rates have *fallen* steadily for the past several decades, which is the opposite of the overall trend in healthcare......right now, a CRNA who practices independently (as about 25% do) pays less in malpractice premiums, on average, than does one in an ACT practice. How does that work, if they are a risk?

Be as dismissive as you want, but CRNA's and NP's are steadily gaining autonomy and a larger role in healthcare, whether you like it or not.



medicsb said:


> of an MD or DO - no one should be allowed complete autonomy to practice medicine


Under what authority does the medical lobby proclaim to have the only right to provide healthcare? Just because "that's how it's always been"?

That paradigm is over, brother. That ship has sailed and given the current state of healthcare, with the ultra-demand for value and cost control, it is never coming back.

The medical lobby pretty much shot itself in the foot when for decades they artificially inflated demand for their services (and thus their income) by intentionally maintaining shortages in certain specialties. They essentially created a vacuum that the market decided to fill with other providers.


All of this may seem off-topic, but it's actually not....the reality is that these are issues that may affect paramedics as they push for a greater autonomy and a wider scope of practice.


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## Shishkabob (Feb 6, 2013)

JPINFV said:


> Also you shouldn't care what a pathologist or pediatrician thinks of EMS.



Had an ER physician call me an ambulance driver last night when a patient said they wanted to speak with me.

While looking at the physician, but directing the verbal response to the patient, I said "Sorry (patients name), I didn't go to school for 2 years to be called an ambulance driver"


It's one thing if a GP said that, another completely when a physician at a level 1 trauma center that works daily alongside my medical control says that.


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## JPINFV (Feb 6, 2013)

old school said:


> Studies of such "dubious quality" that they have been accepted by CMS, the Institute of Medicine, and many if not most state hospital associations, all which have issued statements or directives arguing for expanded use of APN's "to their fullest potential".



You mean a bunch of agencies who care more about cost than quality want the cheaper option? Color me shocked. 


> Here's something to chew on: The salaries that anesthesiologists demand are in most cases significantly higher than the revenue that they generate. This means that the large hospitals lose money on every anesthesiologist that they employ.
> 
> CRNA's, on the other hand, can bill for the same amount as MD's, yet are perfectly happy working for HALF what an anesthesiologist requires......now how do you think that's gonna wash out when the Affordable Care Act takes full effect and hospitals get so tight for dollars that they have no choice but to start making really tough decisions about cutting services and looking at who and what is really cost effective?



You think that hospitals employ physicians? Cute. The  anesthesiologist's group is contracted through the hospital and is going  to bill independently. 



> And if CRNA's are unsafe providers, then explain why their malpractice rates have *fallen* steadily for the past several decades, which is the opposite of the overall trend in healthcare......right now, a CRNA who practices independently (as about 25% do) pays less in malpractice premiums, on average, than does one in an ACT practice. How does that work, if they are a risk?



You mean providers who take the least risky cases have lower malpractice costs? Fun fact, university hospitals tend to have higher mortality rates. Residents aren't always the reason. Another is that those hospitals are more likely to accept the cases that no one else will touch. Likewise, anesthesiologists are more likely to touch high risk cases that CRNAs won't... and shouldn't... touch. However I guess we should deny those people health care because it's just to risky? 



> Under what authority does the medical lobby proclaim to have the only right to provide healthcare? Just because "that's how it's always been"?


 
Under what authority do NPs and PAs have to claim the right to practice medicine? 




> The medical lobby pretty much shot itself in the foot when for decades they artificially inflated demand for their services (and thus their income) by intentionally maintaining shortages in certain specialties. They essentially created a vacuum that the market decided to fill with other providers.



...because residencies can be funded and opened on a dime... right? 



Also... we still don't know what your conflict of interest is here. Are you a noctor student?


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## Chris07 (Feb 6, 2013)

old school said:


> That paradigm is over, brother.



Out of curiosity...then why do we need doctors? If I can see a fully autonomous NP for half price why on earth would I want to see a physician?

If the paradigm is over why are we not phasing out physicians and replacing them with autonomous mid-level providers, since we've already established that they are more cost effective? 

I'm sorry but something has to seperate a physician from a mid-level besides the kind of school they go to and the letters before/after their name. I believe full autonomy should be that element of separation. I mean if I can be autonomous as an NP/PA...why the heck should I go to med school?


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## Aidey (Feb 6, 2013)

Back on topic. Now. The next person that posts about RNs vs MDs vs Anyone is going to be the object of my complete and undivided attention.


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## JPINFV (Feb 6, 2013)

Redacted


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## ExpatMedic0 (Feb 7, 2013)

Ok if all the medical students and nurses are done playing grab ***.... :wub:
 I have a few questions...

Is anyone aware of anywhere in the U.S. other than Colorado and Minnesota with Community Paramedic pilot programs?

The current training/education for these pilot programs are embarrassing low considering the idea of this concept and what these providers are doing. Here is one such example below. Kind of like an EMT-I type of an idea compared to a Paramedic, only filling a mid level provider role, which is kind of scary.


Phase 1—Foundational Skills (Approx. 100 hours, based on prior experience) Comprehensive didactic instruction in advocacy, outreach and public health, performing community assessments and developing strategies for care and prevention
Phase 2—Clinical Skills (Range of 15 to146 hours, based on prior experience) Supervised training by medical director, nurse practitioner, physician assistant and/or public health provider.


Now compare that with the Masters degree in Australia for the same provider role and title..... Makes me laugh.


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## Tigger (Feb 7, 2013)

schulz said:


> Ok if all the medical students and nurses are done playing grab ***.... :wub:
> I have a few questions...
> 
> Is anyone aware of anywhere in the U.S. other than Colorado and Minnesota with Community Paramedic pilot programs?
> ...



I am only aware of two in Colorado and there's very limited information in terms of their education. Have you found much in the way of curriculum for Western Eagle County's program or Ute Pass Regional Ambulance's? I know someone at the latter, I'll try and get the scoop on that at some point.


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## Summit (Feb 7, 2013)

Tigger said:


> I am only aware of two in Colorado and there's very limited information in terms of their education. Have you found much in the way of curriculum for Western Eagle County's program or Ute Pass Regional Ambulance's? I know someone at the latter, I'll try and get the scoop on that at some point.



WECAD is a very small rural service with 4 ambulances. They do not charge for CP visits and it is entirely funded by grants.Their CP course is an online non-credit course taught through the local community college combined with a 32 hour lab and 100 hour clinical. 

When you look at their talking points for MDs:
http://www.wecadems.com/documents/MD Talking Points.pdf

You see that CP is aimed squarely at a well established realm of nursing. CP roles are clearly doubling into Community Health Nursing roles, a profession that requires a BSN at minimum.


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## Tigger (Feb 7, 2013)

Summit said:


> WECAD is a very small rural service with 4 ambulances. They do not charge for CP visits and it is entirely funded by grants.Their CP course is an online non-credit course taught through the local community college combined with a 32 hour lab and 100 hour clinical.
> 
> When you look at their talking points for MDs:
> http://www.wecadems.com/documents/MD Talking Points.pdf
> ...



That seems pretty thin truth be told. Ute Pass's PACT program is even smaller (they run 2-3 ambulances) and while it is respected within the community I cannot imagine the actual education component is significantly longer than WECAD's. 

There seems to be a lack of formalized education programs for community paramedics that are of what most of medicine would consider to be of proper depth. While I don't think it's unreasonable to think that many of the public health initiatives championed by community paramedic programs can be learned in a few hundred hours, that is not going to get any respect from the rest of the medical community that did not take this perceived "shortcut" to get to this role. 

Also WECAD and Eagle County Ambulance District are in the process of merging, it will be interesting to see if the community paramedic program is maintained, expanded, or scrapped.


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## usalsfyre (Feb 7, 2013)

Summit said:


> You see that CP is aimed squarely at a well established realm of nursing. CP roles are clearly doubling into Community Health Nursing roles, a profession that requires a BSN at minimum.



While the shortcut aspect is a legitimate concern, if community health nursing had been adequately filling this niche community paramedicine wouldn't be in existence.

MedStar is showing you can have similar outcomes with community paramedics at lower cost...isn't that the entire argument behind APNs?


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## Veneficus (Feb 7, 2013)

What everyuone arguing economics is failing to realize is you can send a specifically trained tech to any condition, in any environment, from surgery to EMS and get results that look good using guidlines.

About 100 years ago, a doctor could become so in the US with an apprenticeship not a formal education. Surgeons didn't always go to medical school.

The reason that such strict criteria for the practice of medicine exists is because of that. 

Medical education costs and artificial shortage in doctors is easily remedied by doctors.

This same thing is going to play out with nursing and EMS.

But as I have saidin PM, these band-aid fixes require a dysfunctional system. A system which will not be able to sustain another 100 years.

This rol filling is not optimal, it is simply better than nothing, and since the future of medicine is individualized genetically based treatment, not guidlines and protocols, comparing oneself and results to current guidlines is not going to work forever. It may not even work for the next change of guidelines.

I am of the mind that the only long term viable and portable careers in healthcare is basic nursing and doctors.

I also agree that if EMS is to remain a viable career, it will have to grab hold of community medicine from nursing and they need to start doing that ASAP if they want to succeed. 

I also stated and stand by the point, mid level providers are middlemen and do not exist in viable much less economical healthcare systems. When it comes to savings, middlemen will always be cut before those at the top and bottom. IF there is a realistic shift in US medical policy to train an adequete amount of doctors for the population and not based on market manipulation, midlevels will be competing with doctors for jobs, and I am willing to bet I know how that will work out.

As anyone in business can attest, filling a need doesn't mean the need will always exist.


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## Tigger (Feb 7, 2013)

usalsfyre said:


> While the shortcut aspect is a legitimate concern, if community health nursing had been adequately filling this niche community paramedicine wouldn't be in existence.
> 
> MedStar is showing you can have similar outcomes with community paramedics at lower cost...isn't that the entire argument behind APNs?



While I agree that community paramedics would not exist without community health nursing dropping the ball, it seems to me that nursing in is in a much better position to get it back than EMS is to keep it. 

EMS has little lobbying power and the educational differences between a community health RN and community paramedic are significant. The community paramedic model is only sustainable because as you said, it provides similar outcomes at a lower cost. 

But what happens when the CP model starts to expand and there is no expansion in education with it. Can the similar outcomes can be maintained at a larger scale?


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## Summit (Feb 7, 2013)

Tigger said:


> While I agree that community paramedics would not exist without community health nursing dropping the ball, it seems to me that nursing in is in a much better position to get it back than EMS is to keep it.
> 
> EMS has little lobbying power and the educational differences between a community health RN and community paramedic are significant. The community paramedic model is only sustainable because as you said, it provides similar outcomes at a lower cost.
> 
> But what happens when the CP model starts to expand and there is no expansion in education with it. Can the similar outcomes can be maintained at a larger scale?



Id wager that the shortfall from nursing is a combination of:
1. lack of support from the healthcare system as a whole for preventative care, particularly for undeserved and rural populations 
2. a historic lack of qualified BSN RN providers

#2 isn't a problem anymore with the trend towards BSN entry, completion, and graduate education in nursing. Also, there are more and more nurses looking to get outside the acute care and shift work world. 

#1 will continue to be a problem for community health nursing and CP. But, if there is money, the RNs will be more successful for the reasons stated.

I wouldn't compare CP to APNs. I'd compare it to a FD takeover of EMS. Picture a fire chief saying, why don't I make all my FFs into medics so I can get medical call revenue while they aren't running fires since fire call volume is steadily decreasing, plus the entry barrier to FD is so low I have are billion applicants, so let's add this paramedic thing as another prereq.

Now picture an EMS service director looking for something their medics can do instead of sitting on a street corner or at the ems/fire station. Why don't we send them to an online class, call them community medics, and increase billable services?

The CH RNs focused on HBPC, HH, on other forms of in-home care do this as their primary profession backed by university level community health courses and an entire curriculum that covers the general, chronic, and all aspect considerations for patient care (not to mention a real pharmacology course). They are not techs dabbling in primary/preventative care inbetween 911 calls.


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## usalsfyre (Feb 7, 2013)

So lesser educated providers who get similar outcomes SHOULDN'T take over a healthcare niche in this case? But they should in others? 

I wish y'all would make up your mind...


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## VFlutter (Feb 7, 2013)

usalsfyre said:


> So lesser educated providers who get similar outcomes SHOULDN'T take over a healthcare niche in this case? But they should in others?
> 
> I wish y'all would make up your mind...



Go for it. I wish all the community paramedics the best of luck. I do no predict outcomes will be any better than they are now and most likely be worse. There are just too many aspects to community care to learn in a 200 hour course. 

I have no doubt that paramedics could eventually fill this role however it will not be as easy as some are suggesting and it will definitely require an increase in education including humanities and Gen. Ed.  

There is a differene between lesser educated and under educated. Most, not all, paramedics are undereducated for the jobs they perform now let alone stepping into advanced roles.


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## Wheel (Feb 7, 2013)

Hopefully the CP concept will lead to more education. I think it would be great if an organization (let's take med star as an example) would flesh this idea out. I think it would be great if they would pay for their paramedics to finish the bachelors from uthscsa and an internship both in the field and also other areas (wound care, family practice, er, urgent care clinic.) Then they could make the case that their education was comparable and outcomes similar. That plus their ability to be dispatched to frequent fliers/primary care 911 calls might allow them to make a case for reimbursement.

I'm just thinking aloud here. Might this be an opportunity for ems to push itself into something that meets a need and to make a reason for increased education and subsequently reimbursement?


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## ExpatMedic0 (Feb 8, 2013)

Regarding some of the previous post. 

I think this particular (theoretical)mid level provider would not take jobs from M.D.'s. I think one purpose of this provider would be to save money, cut down on unnecessary hospital visits or M.D. contacts in the first place. Lets face it, an M.D. is not going to be making house calls as a full time job in rural areas or areas of health disparities which will result is no real reimbursement. Also think of all the unnecessary and overcrowded ED's.

It should also be noted I think a mid level provider such as a community paramedic would actually be taking the crap work many do not want which is also not worth very much money. Much of the work would simply be deciding if someone needs to go see a Doctor or not. 

Any mid level provider that is arguing for full autonomy like a Doctor needs to STFU and become a Doctor, problem solved. Nursing, PA, and Paramedic are all built to assist, provide an extension, or work below Doctors in one way or another. Not to practice medicine independently as a fully autonomous provider.

Also this is a "Pre-hospital" environment which I see as EMS's sandbox and as a result, a Paramedic's sandbox if U.S. EMS can get its stuff together, like every other country using this right now.


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## ExpatMedic0 (Feb 8, 2013)

Also I would like mention this is all ready the future of EMS in the USA. 

I would like to quote the National Highway Traffic Safety Administration (NHTSA), the Health Resources
and Services Administration (HRSA) the National Association of EMS Physicians (NAEMSP) and National
Association of State EMS Directors (NASEMSD).

"Emergency Medical Services (EMS) of the future will be community-based health management
that is fully integrated with the overall health care system. It will have the ability to identify and
modify illness and injury risks, provide acute illness and injury care and follow-up, and
contribute to treatment of chronic conditions and community health monitoring. This new entity
will be developed from redistribution of existing health care resources and will be integrated with
other health care providers and public health and public safety agencies. It will improve
community health and result in a more appropriate use"

source: http://www.ircp.info/Portals/22/Future/FinalEducationAgenda.pdf


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## Summit (Feb 8, 2013)

schulz said:


> Also this is a "Pre-hospital" environment which I see as EMS's sandbox and as a result, a Paramedic's sandbox if U.S. EMS can get its stuff together, like every other country using this right now.



Paramedics date to the early 1970s. EMERGENCY prehospital medicine is *E*MS's sandbox in the US. Preventative and home care in the US is the realm of RNs (and in the past, MDs) and increasingly, telemedicine (which is awesome and managed by physicians, midlevels, and RNs).

Community Nursing in the USA dates back to 1877. Community paramedics to what, the 2000s?

Paramedics are not going to take the role as a positive development in the US unless their educational minimums advance drastically (to where most of the regular posters on this forum want them to be). 

I predict that community paramedics will continue to develop in small programs in rural areas where the ALS services have very light call volume. I do not think it will happen in urban areas unless there is and education revolution in EMS. In the urban and suburban environments where EMS has a higher call volume and BSN RNs are plentiful, how does it make economical sense to dispatch two paramedics in an ambulance when you could dispatch one better educated and focused CHRN in a compact car?


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## ExpatMedic0 (Feb 8, 2013)

Summit said:


> how does it make economical sense to dispatch two paramedics in an ambulance when you could dispatch one better educated and focused CHRN in a compact car?


I am going to be careful how I answer this because if we are going to get into another career penile measuring contest, I would prefer to be in another thread 

IMO I think a Paramedic with years of field experience and a college degree in a related field that is relevant would be a better fit.

One of the main goals of this is not only to provide a level of care that otherwise not be there, along with public health but to mainly reduce ED visits.  A seasoned Paramedic is already trained and experienced in recognizing and treating emergencies.  All Paramedics are also trained to operate alone outside of a hospital or clinical environment. 
 However most importantly, we are all ready responding to many of these calls. Just being forced to transport in many cases when its not necessary. Community Paramedics have been shown to reduce ED visits by over %40 http://ircp.info/Portals/22/Downloads/Expanded Role/NAEMSE Community Paramedic Article.pdf
Regardless of what healthcare system your using, that saves money.. It also allows Doctors at the hospital to treat more important patients and matters. Some(not all) Paramedics are more than prepared to meet the needs of the community if there given the right tools and education to do so. In fact, IMO there Ideal for this.


In order for this succeed like it is in all the other modern countries in the world... Its going to take a more advanced understanding of disease process, A&P, and public health than a certified Paramedic. These issues have already been addressed and inter-graded into the curriculum for many of the community Paramedic degrees/programs outside the USA. 

And although certainly not the majority at this time, there are plenty of degree baring Paramedics in the USA (more than enough to conduct pilot programs at this time) who already posses many of those qualities. In addition to that if you gave them recognition of prior learning through field experience, I believe many of them are highly capable with a simple upgrade of public health and disease process.
However I would like to see a more formal curriculum develop in the states specific to the community paramedic which also meets the needs I mentioned above. The link I posted to the aussie community paramedic degree would be something to go off of.


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## Summit (Feb 8, 2013)

schulz said:


> IMO I think a Paramedic with years of field experience and a college degree in a related field that is relevant would be a better fit.



The argument could be made for that in combination with sufficient education in community health, but the current programs do NOT require any of these things. So, saying that is little different than wishing for a BS or MS minimum for paramedics.



> One of the main goals of this is not only to provide a level of care that otherwise not be there, along with public health


Thus my statement that CP programs will probably continue to exist in small rural districts.



> A seasoned Paramedic is already trained and experienced in recognizing and treating emergencies.  All Paramedics are also trained to operate alone outside of a hospital or clinical environment.


Working alone outside the hospital is exactly where the CHRN is educated and trained to practice. They are also trained to recognize emergencies and respond appropriately (possibly calling 911).



> However most importantly, we are all ready responding to many of these calls. Just being forced to transport in many cases when its not necessary.


Sounds like a great reason to have a CHRN in a fly car.



> Paramedics are more than prepared to meet the needs of the community if there given the right tools and education to do so. In fact, IMO there Ideal for this.


That is a huge IF that simply isn't happening. They are NOT ideal for this because their education is NOT ideal for community health.



> In order for this succeed like it is in all the other modern countries in the world... Its going to take a more advanced understanding of disease process, A&P, and public health than a certified Paramedic. These issues have already been addressed and inter-graded into the curriculum for many of the community Paramedic degrees/programs outside the USA.


I agree... but that is not how it works here, nor how it will work anytime soon (I say that with great sadness).

Wishfull thinking about what paramedicine should be is not a valid reason for paramedicine to prematurely take on roles that would be appropriate ONLY AFTER the progression becomes reality.


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## Shishkabob (Feb 8, 2013)

Summit said:


> Thus my statement that CP programs will probably continue to exist in small rural districts.



Or the 16th biggest city in the US (Or #9 based on population of service area)


 MedStar Making House Calls


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## ExpatMedic0 (Feb 8, 2013)

I think what is important to remember here is that no program really exists yet. There are 1 or 2 experimental pilot programs in the states right now that are in the VERY early stages of researching this further. ( that I am aware of)

This already exists and is in practice in England, Aus, Canada, so on and so forth. There are 20+ universities in the United States pumping out Bachelor degree baring Paramedics with education to do this, they just need a little more information on disease process and public health. They in no way represent the majority of certified Paramedics in the USA but neither does community Paramedicine. 


 If we want to talk about nursing and CHRN's maybe allnurses.com would be a good resource. If we could stay on topic it might help this thread provide further information for those of us who interested community PARAMEDICINE


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## Summit (Feb 8, 2013)

schulz said:


> There are 20+ universities in the United States pumping out Bachelor degree baring Paramedics


That makes up, what, 1% of US programs?



> If we want to talk about nursing and CHRN's maybe allnurses.com would be a good resource. If we could stay on topic it might help this thread provide further information for those of us who interested community PARAMEDICINE



Discussing CHRNs is absolutely appropriate in a discussion about paramedicine expanding into an area that has been the realm of CHRNs for a very long time. I don't see why it would be a bad idea to have a CHRN work for an EMS system as a colleauge of the providers and resource of the EMS system function in that PH/CH role. Afterall, if since you mentioned many other nations using baccalaureate equivelent and masters prepared providers in a community health role, it is worth noting that many countries use EMS providers while others use nurses including prehospital specialized nurses.

ETA: I guess what I am saying is that you've come up with all of these changes that you (and I) think paramedics need to make in their educational system to properly fill a role, but the changes haven't occured. The role can be filled by an CHRNs produced by the current system, so WHY NOT incorporate BSN RNs in that sub-role within the EMS system?


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## VFlutter (Feb 8, 2013)

schulz said:


> It should also be noted I think a mid level provider such as a community paramedic...



Calling a community paramedic a midlevel provider is a joke unless their educational requirements will be equal to that of NP/PAs. Good luck getting prescriptive rights.  



schulz said:


> Also this is a "Pre-hospital" environment which I see as EMS's sandbox and as a result, a Paramedic's sandbox if U.S. EMS can get its stuff together, like every other country using this right now.



Just because community medicine happens outside of the hospital does not automatically qualify paramedics as the most suitable providers. Community health is about preventative care and management of chronic disease which has never been the focus of EMS.  




schulz said:


> IMO I think a Paramedic with years of field experience and a college degree in a related field that is relevant would be a better fit.



I do not see how a few years field experience will adequately prepare them. What do you consider a related field?

Will they be prepared to teach that patient with a new Ostomy? Or help manage a schizophrenic off his meds who has inadequate nutrition and no way to afford his medication?  



schulz said:


> If we want to talk about nursing and CHRN's maybe allnurses.com would be a good resource. If we could stay on topic it might help this thread provide further information for those of us who interested community PARAMEDICINE



I think a multidisciplinary discussion is important to fully explore the topic. That is what is great about the website. And much like how paramedics jump on any topic about a RN wanting fill a paramedic role, RNs have interest in this topic. Pushing RNs out of the discussion is not going to help. 

At some point in this community paramedic movement the Nursing lobbies will get involved.


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## usalsfyre (Feb 8, 2013)

It's very, very interesting to see the vitriol hurled out when someone else sets up shop in nursing's perceived "turf", despite the nursing lobbies constant forays into everyone else's. Perhaps this would be a good place to start next time someone ask about PHRN or "challenging" the NREMT.


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## Shishkabob (Feb 8, 2013)

Chase said:


> preventative care and management of chronic disease which has never been the focus of EMS.



Oh you mean how like NOTHING medical was ever the focus of nursing until the 20th century, and everything before then was actually more, well, nursing related and general patient care like what CNAs do now?


Hmph, funny.


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## Carlos Danger (Feb 8, 2013)

I am not the least bit opposed to the idea of a community health paramedic, but frankly, I just don't see how it would work.

First, I think we need to define our terms. What are we really even talking when we discuss "community health paramedics"? Are we talking about a paramedic who has an extra hundred or so hours of in-service training and is intended to make house calls for dressing changes and trach care in between 911 responses, or are we talking about a graduate-education prepared clinician who provides actual primary care in the home? I see references to both models throughout this discussion, and they are very different things.

The first model is probably quite feasible. I would imagine that a 100-hour or so standardized curriculum could be developed _(they already have been, apparently, in a few places)_, and possibly even a new level of national certification eventually created, and that it probably wouldn't be too hard for EMS agencies to contract with CMS payers and other insurers to provide some basic care at a lower cost as compared to home care RN's.

The latter model, however - the "primary care paramedic" - which is I think is what most of us have in mind, would be a dramatically greater challenge. To the extent that I actually don't see it happening anytime soon, if ever. For several reasons:


*Education:* The only other non-physician primary care providers in the US are PA's and FNP's. Both require a masters-level education, while a majority of paramedic programs are still two-semester vo-tech certificate programs which use textbooks written at a 10th grade reading level and require no college-level science or social science courses. I've been a paramedic for 15 years and in that time, even though the topic of education has always been an issue, almost nothing has improved. The whole "EMS is in it's infancy" thing is a BS excuse. We know we are undereducated, and we've known it for a while now; the problem is not the age of the profession, it is that as a profession we just don't have the will to change. 


*Legal / regulatory:* There is no licensure in any state (that I'm aware of) for a paramedic to practice primary care. Changing that will be a MASSIVE battle in some or most states. The nurses will fight tooth-and-nail, and the physicians will too, in some cases. And both the nurses and the doctors have a lot more money and a lot more lobbying power than EMS. It isn't fair, but it is reality. 


*Competition / market demands:* No matter how great of an idea it is, you can't do it for a living if you can't convince someone to pay you for it. And I don't see much market demand for in-home primary care. There's some, and I would expect it to increase over the next couple of decades, and some populations are already underserved, but most of the needs are already filled by home care nurses, and if there were really a huge demand for in-home primary care, I think you'd see more services like this one: Metro Medical. So the business model exists, but it seems like there'd be a lot more of this if the demand was really there.


*Reimbursement:* I see this as the least of the challenges, probably, but still a challenge nonetheless.


*Lack of interest:* Universities are not going to develop and set up expensive new graduate educational programs for a small handful of students. There would need to be a significant demand for such programs, and I don't see there being nearly enough paramedics with both the interest and requisite undergrad education to justify the cost to the universities.

Rather than starting from scratch, the most realistic option might be something like convincing a PA program to design a somewhat-abbreviated "paramedic track" program for paramedics with appropriate undergrad education. This program would take into account and grant credit for paramedics' existing knowledge and skill sets, and would focus on in-home primary care and perhaps even medical direction of paramedics. That would be a tough thing to set up, and would require the strong support of stakeholders in the healthcare community.


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## VFlutter (Feb 8, 2013)

usalsfyre said:


> It's very, very interesting to see the vitriol hurled out when someone else sets up shop in nursing's perceived "turf", despite the nursing lobbies constant forays into everyone else's. Perhaps this would be a good place to start next time someone ask about PHRN or "challenging" the NREMT.



Then I guess I should pull out the cliché "If you want to piss in my sandbox then go to nursing school" line.


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## Carlos Danger (Feb 8, 2013)

usalsfyre said:


> It's very, very interesting to see the vitriol hurled out when someone else sets up shop in nursing's perceived "turf", despite the nursing lobbies constant forays into everyone else's. Perhaps this would be a good place to start next time someone ask about PHRN or "challenging" the NREMT.



A lot of animosity towards nurses on this forum.

It's really too bad, considering the vast amount that the paramedic profession could learn from the nursing profession.


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## NomadicMedic (Feb 8, 2013)

Attention!

We're going to close this thread for a day or two and let everyone cool down. We've warned you several times about the "paramedics vs nurses" thing... 

The CLs will have a discussion to see if we want to let this continue.


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