# CALIFORNIA Title 22 regulations change



## socalmedic (Oct 28, 2012)

time for another comment period, please everyone if you are in CA read the document and share your feelings with your agency!!! this is our chance to make a change for the better.

this link will be open until november 8th, 2012

http://www.emsa.ca.gov/about/Public_Comment.asp#pmed


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## socalmedic (Oct 28, 2012)

§100158 (b)
Page 27
Line 10	

LA CO EMSA	

- Add “associates degree or higher in an allied health field”.

The Agency feels this an opportune time to elevate the level of the professional paramedic.	

CA EMSA response

Comment acknowledged. No change. There is currently no data to support the necessity to place additional higher education at this time. 

-Adding more education will limit the pool of paramedics.


for once LA County actually has the right idea and they are shot down. this state is F*&%$ed.


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## JPINFV (Oct 28, 2012)

It's very interesting to see who's for expanding the education of EMS providers and who isn't. I especially loved the "How dare EMS personnel's training and scope overlap with physicians and nurses" comment.


On the bright side, most of the arguments surrounding removing parts is a "It's not enough training," not "Paramedics shouldn't be doing ____."


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## AnthonyM83 (Oct 28, 2012)

socalmedic said:


> §100158 (b)
> Page 27
> Line 10
> 
> ...


I would encourage you all to send post additional support for this. We have a lot of members here and overwhelming comments about increasing education might not change their minds, but at least make it an issue.

*****Please post a comment to them****
Under the "October 25 - November 8"  Comment Form (in bold)


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## socalmedic (Oct 28, 2012)

I agree, alot of Ideas and responses are pro EMS, Props to Dr. Becker. 

Excerpts I found entertaining, 

"You are trying to create a Critical Care Paramedic to replace the CCT-RN with this expanded scope and appalling minimal hours of training!
The Paramedics are doing less and less in the field and for good reason.  Their scope of practice should be reduced not expanded. How can you justify a Paramedic in the Critical Care setting? Chest tubes, Ventilators, Blood products, gtt’s – heparin, Tridil, TPN, Levophed and the rest should all be removed. Is there even a good reason for them to hang Dopamine? Really? How can you really justify turning a paramedic into an ICU nurse in a few hours….really?  This will put humans at an undue risk and really open the door for future devastating risk management expenditures." --Falcon CCT.

Emsa response-- "comment acknowledged" 
--

"The draft Regulations are a stroke of brilliance on the part of the Authority"-EMDAC


--
"If a Physician Assistant, Registered Nurse or Physician challenges the Paramedic regulations per § 100165 (c) (1-3) and succeeds at earning CA Paramedic licensure, would they be required to work for an ALS provider for three years before being eligible for CCP training?" -Lynch Ambulance

Emsa Response
"Comment acknowledged. No change.  If a physician assistant, registered nurse or physician challenges the paramedic course and succeeds at earning a CA paramedic license, the individual will have to comply with the requirements to gain accreditation as a certified CCP"

My response, maybe a doctor can skip the tree years, but finally nurses stop getting a front of the line pass!


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## socalmedic (Oct 28, 2012)

AnthonyM83 said:


> I would encourage you all to send post additional support for this. We have a lot of members here and overwhelming comments about increasing education might not change their minds, but at least make it an issue.
> 
> *****Please post a comment to them****
> Under the "October 25 - November 8"  Comment Form (in bold)



I have been sending them requests to increase training and education at every comment period. I have gotten a few personal emails back regarding expense to the "public ems providers" ie fire departments. orange county and san diego county seem to be aggressively perusing eliminating the CCT part, at least EMSA has the balls to say "no change, the LEMSA will decide staffing and procedural issues" and we have only seen minor resistance from ENA and CPF, they seem to be all for CCT medics.


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## JPINFV (Oct 28, 2012)

socalmedic said:


> --
> "If a Physician Assistant, Registered Nurse or Physician challenges the Paramedic regulations per § 100165 (c) (1-3) and succeeds at earning CA Paramedic licensure, would they be required to work for an ALS provider for three years before being eligible for CCP training?" -Lynch Ambulance
> 
> Emsa Response
> ...




Who cares? There's already mechanisms in place to allow RNs and physicians to supplement an EMS crew of EMTs to provide critical care transports. It's basically asking to save 12/hr on an EMT.


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## Akulahawk (Oct 28, 2012)

JPINFV said:


> Who cares? There's already mechanisms in place to allow RNs and physicians to supplement an EMS crew of EMTs to provide critical care transports. It's basically asking to save 12/hr on an EMT.


Not only that, but of a registered nurse is also certified as an EMT, that fulfills the requirement for having a 2nd EMT on an ambulance. That would mean that the company would be able to have 2 crewmembers onboard: an RN/EMT and EMT as a driver. During transport, the RN/EMT would function as an RN, with full scope as needed. The EMT certification would simply be something used to fulfill a regulatory need.


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## JPINFV (Oct 28, 2012)

Akulahawk said:


> Not only that, but of a registered nurse is also certified as an EMT, that fulfills the requirement for having a 2nd EMT on an ambulance. That would mean that the company would be able to have 2 crewmembers onboard: an RN/EMT and EMT as a driver. During transport, the RN/EMT would function as an RN, with full scope as needed. The EMT certification would simply be something used to fulfill a regulatory need.




Just curious, do you know that for sure or is it conjecture? I can completely see someone who is licensed as an EMT and as something else being required to operate at an EMT level when being used to fulfill minimum staffing requirements.


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## Akulahawk (Oct 28, 2012)

Some of the things that I thought were rather interesting is that EMS has removed the APP paramedic. Something else that caught my eye was that they are not considering the FP – C certification for critical care transport, requiring a specific CCP course instead.  It just does not make any sense to me that they will not accept FP-C course completion as an acceptable alternative to a CCP course, yet someone who is FP-C can serve as an instructor for the CCP course.

I think it was Falcon that was very much against the Critical Care Transport Paramedic, probably because all they do is Critical Care Transport RN. I believe that one of their arguments was that paramedics were possibly going to become, or replace, ICU nurses. I think that the EMSA pretty much smacked them down when they said something to the effect of "we are not going to do that, there is no intention to replace ICU nurses with Paramedics."


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## Akulahawk (Oct 28, 2012)

JPINFV said:


> Just curious, do you know that for sure or is it conjecture? I can completely see someone who is licensed as an EMT and as something else being required to operate at an EMT level when being used to fulfill minimum staffing requirements.


I recall seeing something exactly to that effect a couple of years ago. As you are, hopefully, aware, an ambulance requires 2 EMTs at the minimum to be considered legally an ambulance. The last time that I reviewed the CCT regulations, there was no specific requirement that there be 3 persons on board, just that there be 2 persons certified as an EMT and that there be someone certified in critical care transport (RN or paramedic) on board as well. My understanding is that during a scene response, a.k.a. 911, the RN would be required to function as EMT but during interfacility transports, the RN would have full scope. Another way to look at it is whether or not a critical care transport paramedic ambulance is considered fully staffed legally by having just an EMT and the critical care paramedic onboard. I think you will find that to be the case. The critical care transport paramedic scope of practice would only expand during interfacility transport.


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## Akulahawk (Oct 28, 2012)

Something that I forgot to add in my previous post, before the editing timeframe ran out, was that the local EMS agencies seem to be responsible for minimum staffing within their area. Just doing a quick check of a couple of different EMS agencies policies, one of them requires that there be 2 EMTs and then an RN, RCP, or M.D. be added to that BLS team so that would result in a crew of at least 3 personnel on board. I have seen other local EMS agencies require only 2 certified EMT personnel, one of whom can be additionally licensed as RN or above. It is also kind of different in that I have seen local EMS agencies require for flight purposes that there be  two ALS personnel on board, some say one must be a paramedic, some say one must be an RN. The end result for that is the same: 1 paramedic and 1 RN as minimum staffing. That does not mean that two RNs cannot be on the flight crew, it just means that one of the must also be licensed as a paramedic. So you can see some variation in minimum staffing requirements from system to system.


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## socalmedic (Oct 28, 2012)

APP was taken out during the first comment period, at the request of EMDAC, it never even made it to comment. the ccp course is requirement can be met by any critical care class which meets the allotted time in each category, then completion of the CCP-C test. the CCP-C test was chosen for clarity, there is only one certification test to be used. my feelings are that if you can pass FP-C then CCP-C shouldn't be hard as they are essentially the same.


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## terrible one (Oct 28, 2012)

socalmedic said:


> §100158 (b)
> 
> -Adding more education will limit the pool of paramedics.



HAHA!!! How many more paramedics do they need in CA? This state is so oversaturated it's not even funny.


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## JPINFV (Oct 28, 2012)

Akulahawk said:


> [CA staffing question response]



Ok. I'm pretty sure that LA is the 2+extra rule, and when I was working in OC it was 2 EMTs with an RN and/or RT depending on the call. Personally, if someone is being allowed to function as a member of the minimum staffing (i.e. RNs, physicians, etc) requirement, then I think that they should by and large be allowed to do so under their own license. I don't see how an EMT cert is going to enhance the ability for a critical care RN or a physician to provide care. Sure, there's exposure to things not normally used, like those two long hard boards in the exterior compartment, but that doesn't guarantee competence.


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## JPINFV (Oct 28, 2012)

Akulahawk said:


> I think it was Falcon that was very much against the Critical Care Transport Paramedic, probably because all they do is Critical Care Transport RN. I believe that one of their arguments was that paramedics were possibly going to become, or replace, ICU nurses. I think that the EMSA pretty much smacked them down when they said something to the effect of "we are not going to do that, there is no intention to replace ICU nurses with Paramedics."



...and there's nothing stopping Falcon, or any other company that currently doesn't use paramedics from switching to paramedics.


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## Akulahawk (Oct 28, 2012)

JPINFV said:


> Ok. I'm pretty sure that LA is the 2+extra rule, and when I was working in OC it was 2 EMTs with an RN and/or RT depending on the call. Personally, if someone is being allowed to function as a member of the minimum staffing (i.e. RNs, physicians, etc) requirement, then I think that they should by and large be allowed to do so under their own license. I don't see how an EMT cert is going to enhance the ability for a critical care RN or a physician to provide care. Sure, there's exposure to things not normally used, like those two long hard boards in the exterior compartment, but that doesn't guarantee competence.


I think it pretty much comes from the requirement that ambulances required either 2 EMTs or an EMT and a 1st responder driver to be considered an ambulance. Outside of air ambulances, it seems that EMS agencies and the EMS authority do not consider RNs to be ALS personnel for purposes of staffing. Otherwise, any RN would be able to work on any ambulance and provide their level of care, prehospital or interfacility, with an EMT driver, without any additional training.

I would imagine that states that allow prehospital RNs require that those RNs attend some sort of training program or orientation program that would allow them to function safely in the field.


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## socalmedic (Oct 29, 2012)

Akulahawk said:


> I think it pretty much comes from the requirement that ambulances required either 2 EMTs or an EMT and a 1st responder driver to be considered an ambulance. Outside of air ambulances, it seems that EMS agencies and the EMS authority do not consider RNs to be ALS personnel for purposes of staffing. Otherwise, any RN would be able to work on any ambulance and provide their level of care, prehospital or interfacility, with an EMT driver, without any additional training.
> 
> I would imagine that states that allow prehospital RNs require that those RNs attend some sort of training program or orientation program that would allow them to function safely in the field.



four letters M.I.C.N. I happen to feel the class is a joke, but many places have EMT/MICN as the cct staffing.


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## Akulahawk (Oct 29, 2012)

socalmedic said:


> four letters M.I.C.N. I happen to feel the class is a joke, but many places have EMT/MICN as the cct staffing.


The problem with MICN is that they must be affiliated with a Base Hospital... and they're really not that mobile, nor can they provide field direction while actually out in the field. CalSTAR (as an example) flight RN's aren't hospital RN's when working on their aircraft. UC Davis Lifeflight RN's (back when they had that program) were hospital nurses, and probably were MICN's. 

Generally speaking, though, MICN's are the only non-flight RN's that can provide ALS care in the field. They attend something like 40 hours of classroom training and then do an 8 hour observation where they get some small number of ALS contacts. A lot of that time appears to be learning about the local protocols, learning how to give field direction, what the local scope of practice for the providers happens to be. 

Unless they're specifically authorized to provide prehospital care, RN's are limited to BLS care. I think that's in recognition of the fact that RN's just generally aren't trained for field work.


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## mycrofft (Oct 29, 2012)

RN's can provide ALMOST any care their employer will get them certified for individualy, then establish medical control through standardized procedures and MD oversight/countersignature. Easiest to certify them if there exists a standard and a class, but theoretically an employer could formulate it from scratch. Don't know why this would not theoretically extend to the field, but when techs can do it for less, why use a nurse?


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## socalmedic (Oct 29, 2012)

mycrofft said:


> but when techs can do it for less, why use a nurse?




theres a little more to it than that, sure with the majority of the privates it is a money issue. those of us who have done CCTs with a nurse for any length of time can tell you the horror stories of when nurses have no buiseness in an ambulance. I will name a few below

1. the "MICN with years of CCT Experiance" who demanded that she sit up front and i pop my head through the window if anything happens because she gets car sick...:rofl:
2. the CCT-RN who didnt know how to set up a vent, (the ltv-1200 is not that hard) or work the medsystem 3 transport pump.
3. the nurse who asked us to take another route because the road was "too bumpy"

there are more, but you get the jist, in the 7 years I have been in EMS i have been on hundreds of CCT transports and the nurses in general are well suited for the job. however when you allow anyone with an RN license and an MICN course it is an accident waiting to happen. I am glad that CA is finally getting on board with the rest of the country and seeing that a paramedic can in fact be trained to take the majority of CCT cases. reserve the CCT-RN for the truly critical transfers which are over my head, or better yet, take the ICU nurse who has been caring for that patient with me, I will do all the vent, pump, and misc other stuff that she tells me needs to be done.


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## DrankTheKoolaid (Oct 29, 2012)

And to clarify,  that is Field MICN and not base MICN which is totally different.

 I see alot of great ideas having been presented over the last six months on proposed regulation.  Unfortunately more education isnt high on the list,  And with the California Fire Service official position being against more education,  it is a losing battle.  We need to push for repeated testing both cognitive and psychomotor instead of completing the same exact worthless, CE courses over and over and weed out the bottom end


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## socalmedic (Oct 29, 2012)

Corky said:


> And to clarify,  that is Field MICN and not base MICN which is totally different.



in these parts they are the same. we only have one full time CCT-RN in the county the rest are on call.


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## usalsfyre (Oct 29, 2012)

Looking at the comments, and then who they're from....I'm not sure who's running EMS out there, but it sure as Shiva isn't paramedics.

They're arguing over monitoring things (heparin, NTG and norepi) paramedics in many other parts if the country are initiating.


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## AnthonyM83 (Oct 29, 2012)

In large part, I'm sure it's because paramedics/EMTs aren't as organized as those organizations are. The common paramedic wouldn't even know that those regulations were out for change and public comment. Only the organizations are in the know.


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## socalmedic (Oct 29, 2012)

in the past we have been run by the firefighters special interest groups and the board of nursing. this may all appear small, however this whole thing is enormous for us. two years ago if you had told me there are going to be CCT medics I would have laughed in your face. Dr. Becker is giving us drugs in our basic scope which would previously been allowed only for a CCT. I will take what small anonymity they will allow us, and take baby steps to grow. I am a little disheartened that our minimum education standard of an associates in a health related field was shot down with out even the smallest of explanation. hopefully in 5-10 years we can make changes which will actually affect our status as a "profession". 

in response to your statement about pressors, if you really want to know how much of a jump "monitoring nor-epinephrine" is consider the fact that we have a county which recently removed DOPAMINE! meaning no pressers for the crews in riverside.


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## DrankTheKoolaid (Oct 29, 2012)

All of the stuff they are talking about having to do CCT certification for,  we have been doing in my area for 15 years as basic scope. This is due to our dual role 911 and CCT ifts from the local podunk to the larger distant facilities. 

 Rather unfortunate that the rest of the state is going to suffer because of the inept care provided elsewhere.   There really needs to be a broader state scope and then let the lemsa medical directors water it down based on local need and training standards. 

I will obviously get the cert,  but my point is when your in a rural area how are you supposed to be able to attract CCT employees when pay is much better elsewhere


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## JPINFV (Oct 29, 2012)

In other news, OCEMS just released a bunch of new protocols further cementing the fact that the average OC paramedic is apparently a blithering idiot.


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## socalmedic (Oct 30, 2012)

Corky said:


> All of the stuff they are talking about having to do CCT certification for,  we have been doing in my area for 15 years as basic scope. This is due to our dual role 911 and CCT ifts from the local podunk to the larger distant facilities.
> 
> Rather unfortunate that the rest of the state is going to suffer because of the inept care provided elsewhere.   There really needs to be a broader state scope and then let the lemsa medical directors water it down based on local need and training standards.
> 
> I will obviously get the cert,  but my point is when your in a rural area how are you supposed to be able to attract CCT employees when pay is much better elsewhere



dont forget that California still has the "local optional scope of practices" your nothing local will change as your county has been going above and beyond through these alternate channels. its the same way we have been using versed, amiodarone, CPAP, BPAP, cardioversion, pacing, nasotrachial intubation... the basic scope wont change much, they are just moving alot of the optional skills to the basic scope. 

for instance, I can already monitor IV nitro and heparin because my LEMSA had it approved through the local optional scope years ago. 

I do agree with you that it will be harder for the rural providers to get the training and skills exposure with out having to go to the big city.


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## Akulahawk (Oct 30, 2012)

socalmedic said:


> dont forget that California still has the "local optional scope of practices" your nothing local will change as your county has been going above and beyond through these alternate channels. its the same way we have been using versed, amiodarone, CPAP, BPAP, cardioversion, pacing, nasotrachial intubation... the basic scope wont change much, they are just moving alot of the optional skills to the basic scope.
> 
> for instance, I can already monitor IV nitro and heparin because my LEMSA had it approved through the local optional scope years ago.
> 
> I do agree with you that it will be harder for the rural providers to get the training and skills exposure with out having to go to the big city.


The one thing that I do not like about moving the optional skills to the basic scope of practice is that the local EMS agencies can still remove skills/procedures/whatever from the basic scope of practice, as they see fit. This results in every county having potentially a completely different scope of practice because they do their own thing. I know that the reality is that most counties will have most of the basic scope of practice of paramedics available and in use, and that some will have local optional scopes that are slightly expanded from that basic scope. Personally, I think that if there is a basic scope of practice, all counties should be required to adhere to that and add to that as needed for their particular situation.


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## Christopher (Oct 30, 2012)

socalmedic said:


> ...meaning no pressers for the crews in riverside.



My take after reading the comments is Riverside does not think very highly of its crews and would rather not have them in the first place.

Which is Ok, because the addition of ALS does not necessarily improve any benchmarks. Especially the addition of lousy ALS.


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