# EMT scope of practice



## koconnell (Sep 14, 2009)

I am involved in an Ethics Debate for EMT school, and was given the topic "should EMTs scope of practice be increased?". I have to debate against it, and i am having a very hard time finding any information on this subject! if you know any sites or have opinions on this subject please help!

Thanks!


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## medic417 (Sep 14, 2009)

No.  Why?  The lack of any real medical education in the EMT program would make the addition of any skills a danger to the patients they are around.


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## MrBrown (Sep 15, 2009)

To merit any increase in the scope of practice a substantial increase in the educational requirements would be required.


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## Lifeguards For Life (Sep 15, 2009)

medic417 said:


> No.  Why?  The lack of any real medical education in the EMT program would make the addition of any skills a danger to the patients they are around.


agreed.
what other skills is the "for" side proposing? adding more skills would mean drastically increasing the required training hours for the EMTB course. as of now, the minimum hours for an EMTB course is 110 hours... roughly 3 times the amount of a first responder class. i believe first responder is a 40 hour course with a 4 hour blood borne pathogens portion.


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## fiddlesticks (Sep 15, 2009)

i think it should but i dont know what u guys can do in the US, but my program was longer then 120hrs. so if thats the case then um no it shouldnt be, but i think up here then yeah if your school is cma approved then more skills only help to advance ems.


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## Ridryder911 (Sep 15, 2009)

Actually, the new scope of practice will increase the hours sustainably. Most EMT programs will be at the least of 170 - 200+ hours. 

What will and still confuse most is that the EMS program will be a building block program with emphasis placed in entering from the MFR then EMT then to AEMT then to Paramedic. I do look for institutions to require all EMT students to start with the MFR course as it is designed then use this as a screening and "wash out" to see for those that are really interested to go forward. 

Remember, serious accredited institutions will maintain their entrance admissions and exit admissions within about the 70% range to those that will pass the first time. 

The good thing is many will not ever become wasted EMT's alike now. Most will get their "fix" on being a MFR when they realize that EMS should be a profession and that one will not learn or be able to do any major procedures until about two years later of education. They will be able to purchase their placards, stickers, wear their T-shirts, etc. 

Many need to read the new scope of education as anatomy is definitely "beefed up"; and even public health issues and ethics are now going to be required for even the MFR and EMT portion. 

What does scare me though; is the lack of education for those training and teaching these programs. It will take time but the pendulum is slowly moving to cleanse and remove the "instructor" status for any class above MFR and possibly the EMT level. Even as backwards as my state can be, I am beginning to push my idea of all advanced and Paramedic Educators requiring to have a degree. Now, I am pushing for all EMS educators to be Nationally Certified Educator/Teacher to teach advanced levels. At the least, we will know that they have been exposed and understand different modalities of adult educational theories and methodologies. The very least, we will be able to shift from objective base teaching to focus based instruction. 

Many are not aware at the same time, NREMT is watching and promoting many changes within its own missions. Myself and many other educators have been working with them to increase and change the testing methods. I cannot specifically describe but I will say that I am anxious to see the results of the pilot programs and testing that is proposed. That way we see how testing is currently performed will be drastically changed for the better. Something that us true professionals have been wanting for a long time. 

So to the OP, yes it should be changed as it is going to be changed. No debate, should their skills be increased? No. They need to have a more in-depth understanding of their current level. A increased level of their profession, essential associated science such as anatomy and emphasis on theory of what and why as much as the practicality portion. Institutions should be mandated to have case scenarios within each module and require students to perform such in a atmosphere conducive for realism to increase the needed understanding of the job performance. (i.e. moulaged patients, cut away EMS unit to actually perform treatment in, etc). 

R/r 911


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## koconnell (Sep 17, 2009)

fiddlesticks said:


> i think it should but i dont know what u guys can do in the US, but my program was longer then 120hrs. so if thats the case then um no it shouldnt be, but i think up here then yeah if your school is cma approved then more skills only help to advance ems.



Well i am from canada and i am currently attending school and working in ALberta. Portage College is CMA approved, and i agree some of our skills could be increased but again so will the education. This however is why im struggling with the paper because i think an increase in scope would be good.


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## Smash (Sep 17, 2009)

It would help if we knew what the scope was now, and in what way it can/should be increased.  It is hard to argue one way or another without knowing the starting point.

Enhancing scope of practice (provided proper education and training) may be a very good thing in some areas, but it may be not worth the expenditure of time and money in others.

Some services around the world where medics work in isolated or rural communities have increased the scope of practice to include a wide range of procedures, assessments, drugs and so forth that would not otherwise be available, and as far as I am aware (which is not all that far) these programs have been successful.

However it would be hard to argue for such an increase in scope in a metropolitan area.


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## 281mustang (Sep 17, 2009)

Not with the current training requirements. I'd like to see an increase in EMT's scope of practice, but only after competent standards are developed first.

Edit- One exception I am in favor of is stocking EpiPens on BLS rigs.


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## Bloom-IUEMT (Sep 18, 2009)

*Yes*

The scope of practice for EMTs should be expanded ---along with more education.  
Just peruse this site and you should find a lot of material on this debate. Try this article too:
http://www.emsresponder.com/print/EMS-Magazine/Charting-A-New-Course--EMS-Education-Standards/1$10455


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## CF919 (Sep 19, 2009)

*No*

The EMT-B scope of practice should not include additional skills.  Thats why there are different levels of EMT "EMT-B,EMT-I, Paramedic"


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## Lone Star (Sep 30, 2009)

EMS at all levels needs to focus on the very nature of what we do; emergency medical interventions/treatment.  In order to do this, we must actually focus on the ‘medical part’ of what we do, and why we do it.

There are many things in EMS that needs to change, we all see it.  The question is this:  How do we get those in a position to do something about it to listen to our concerns, and then take the appropriate measures to advance EMS as a PROFESSION; as opposed to it remaining nothing more than a ‘job’?

One of the main things we can do is to eliminate the 'patch mill schools' and start to focus more on quality education than 'training'.  After that, we may see the scopes of practice actually start to widen; with more autonomy in the field.


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## Wee-EMT (Oct 4, 2009)

koconnell said:


> Well i am from canada and i am currently attending school and working in ALberta. Portage College is CMA approved, and i agree some of our skills could be increased but again so will the education. This however is why im struggling with the paper because i think an increase in scope would be good.



EMT in Alberta is totally different then an EMT in the states. There EMT is equivalent to our or less then our EMR. Anyways, I have heard rumors that our scope is increasing. We will soon be able to do intubations, more drugs and 12 leads. (we already do LMA's and King's, why not just give us something to see with!)  I have been told Jan 2010 when the government has officially taken over all services.


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## MrBrown (Oct 4, 2009)

Once we increase the scope of knowledge we can look at increasing the scope of practice.

In an ideal world here's what I would like to include in an entry-to-practice program:

*Part 1: Social and Biological Science*
- Anatomy and physiology on *all* systems (in-depth cardiac, resp, nervous and endocrine)
- Fundamental pharmacology/pharmokenitics
- Fundamental general pathophysiology
- Fundamental medical terminology
- Lifespan development/differences 
- Communication and interpersonal relations
- Research methods and statistics

*Part 2: Prehospital Medicine*
- Core skills (scene safety/BSI, scene management, vital signs, PCR/handover)
- Kinetics and pathophysiology of trauma
- Management of trauma (shock/fractures/c-spine etc)
- Pathophysiology and rationale for management of medical pt's
- Management of medical pt (cardiac, diabetes, asthma etc)

*Part 3:  Practical*
- Clinical logbook (skill utilization and link to evidence/rationale)
- Number of shifts in ED/ICU/CCU
- Driving/EVOC

I envisage this course would take around a year full-time and the following specific outcomes would be required to be met.

- Critically analyse a number of peer-reviewed journal articles
- Complete a number of cases with a clinical mentor (say 5-10 calls)
- Assemble a portfolio of evidence (clinical logbook - say 20 calls)
- Pass a viva voce assessment
- Pass a high fidelity simulation suite assessment (say 5 each medical and trauma)
- Write up PCRs and do handovers for each of the simulation suite patient
- Participate in at least two mass casualty incident simulations

The following would be an appropriate scope of practice 

- OPA
- NPA
- Supraglottic airway
- Tourniquet for the control of severe bleeding unresponsive to direct pressure
- 3 and 12 lead cardiac rhythm acquisition 
- Automated external defibrillator 
- Non narcotic analgesic
- Acetaminophen
- Aspirin for acute chest pain consistent with possible myocardial ischemia (perhaps clopidogrel too)
- Vasodialator for chest pain consistent with possible cardiac ischemia and acute CHF
- BGL measurement
- Oral glucose for conscious patient with hypoglycemia 
- IM glucagon for hypoglycemic patient with an altered level of consciousness
- Nebulised B-agonist for bronchospasam consistent with asthma and anaphylaxis
- IM adrenergic agonist for severe asthma
- Nebulised adernergic agonist for severe anaphylaxis and severe croup
- IM/IN opiod antagonist for ALOC consistent with suspected narcotic overdose 
- PO anti-emetic for severe vomiting 

Although the education is not quite as comprehensive the scope of practice listed above is that of our Ambulance Technician (BLS) with the exception of adrenaline and naloxone.


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## rescue99 (Oct 4, 2009)

MrBrown said:


> Once we increase the scope of knowledge we can look at increasing the scope of practice.
> 
> In an ideal world here's what I would like to include in an entry-to-practice program:
> 
> ...



Absolutely not! The Basic EMT is THE primary transfer care provider serving several million of our infermied and elderly each year in the U.S. The wage ceiling will never support the sort of requirements proposed here. EMT is a such a vital part of our EMS system. We have to make it attractive because there is a revenue ceiling, period. The overhead cost of using Paramedics to do basic back and forth calls all day, everyday largely outweighs the need to increase education demands, period.....so we wait! Wait for what? That's a whole other can of worms best left alone. The debate would raise the roof!  

 I am all for making Basics the current EMTI-85 and increasing MFR to EMR at the current Basic level. Increasing pre-reqs for Basic/Medic to minimally include Basic Bio, Med Term, A/P and introduction to Pharm (minimally) will greatly enhance the existing provider level IMO. It is a cost affective, affordable compromise and points education in the right direction. Problem is, we're in a hurry and attempting to go from 0-60 in a few seconds when that isn't the way things work. It isn't the way business works and education is a business. Huge changes take time to develop and time to implement, period! 

  EMR needs more A/P, Med Term and more Pharm but, consider the job. Cost vs usage pops into the picture once again. Much of the rest of the above proposed ideas are already a part of any decent accredited program and definitely part of any accredited Medic Program...around here anyway.


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## Melclin (Oct 5, 2009)

Mr BROWN AND RESCUE99: 

Rescue, 15 years ago our equivalent of basics, called Ambulance Officers at the time, were required to have more education than what brown mentions to practice at a lower level than he has detailed. What he's suggesting sounds perfectly reasonable as far as educational requirements go.

Brown, how is the 911/IFT divided over your way? When I talk to these yanks about education I forget that the IFT side of it gets included in EMS. Here non emergency IFT is a completely separate world of small privately run organizations similar to the US and education requirements for the "NEPT officers" are significantly lower. That is acceptable to me. You don't need a degree to drive a dialysis pt to a clinic or taxi olds too their medicals. If you required it the system would go down the toilet. But the idea that NEPT officers (slightly better educated than EMT-Bs ) would ever be involved in 911 work is pretty abhorrent (although they are sometimes in incidents involving many casualties with minor injuries, but simply as extra transports).

*TO the rest of the thread*: It seems whenever you guys have these BLS/ALS arguments the "you don't need to tube every pt so why do you want blanket ALS", and "pts deserve well educated professionals so they need ALS level providers". It seems to me that this is indicative of the American attitude towards EMS, its all about the skill sets and not about the clinical decision making. Like the only choices you guys have are uneducated EMT-Bs and well educated paramedics who have a long list of 'skills'. Here we spend 3 years at uni to practice at the lower tier. In all that time we don't do any ALS (that's a higher qualification) because we're not learning skills, we're learning how to be clinicians. Why does the ALS skill set HAVE to come with a good education. 

Its like with doctors. Not every patient needs a thoracic surgeon, but when you see your run of the mill, every day GP or primary care doctor, about that cough that won't go away, you still expect them to be educated enough to be able to evaluate you medically and know difference between the cough that's simply a cold that won't go away and a cough requires a thoracic surgeon because its lung cancer. But to have that GP be a good clinician he doesn't need to be a heart surgeon. That's a specific skill set that is occasionally needed, but its not required to be a good clinician, and requiring all doctors to be heart surgeons before they can become GPs would be ridiculous. Now sub in EMT for GP and Paramedic for heart surgeon.

Why can't you extricate the skills from the education? All pre-hospital professionals should be well educated in their craft, just like any other health-care professional. Then some may chose to learn extra skill sets and do their cool ALS stuff.

To be an "EMT" here you go to uni for 3 years..to be educated.
To be a "Paramedic" you return to uni for a year to do your cool skills and more book learnin. But all pre-hospital practitioners must be well educated.  

In the US, "EMTs" go to institution X for a few months and learn some skills. Then your "Paramedics" go to institution Y for, at most, 2 years where they learn more skills and just enough book learnin to get by using those skills. 

I suppose if you feel that EMTs/Paramedics are the eyes, ears and hands of a medical control doc then that's okay, but it sure seems topsy turvey to me.


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## rescue99 (Oct 5, 2009)

Melclin,

I don't "feel" maintaining the same lower standards is the answer. If you read more than on surface, I said yes, requirements must increase but, we have to be realistic. This is the U.S. and we do have complex layers to our massive public safety, education and  health care systems. We cannot simply change on a dime. It takes years to implement each phase and years to acclimate to them. To do anything else would cause huge gaping holes to form and patients would be the ones falling through the cracks. Aussie might be happy but patients are the first concern here. Let me give an example; 

These past 12 months (3 semesters) we've changed our pre-reqs for all levels of our EMS program at the college. Entry now requires Bio, Med Term, A/P and Pharm, no matter which level. Entry into Medic also requires a Basic EMT license. Change is fantastic but, it means enrollment for the EMS programs went down by 75% and it stayed that way until, well, it's still down! Enrollment will continue to stay low for another 2 semesters while incoming students meet the new requirements for entry. 

This is quite typical of major changes. The college understands change so, it's eating the loss as we transition. Now, picture this country wide. Heck, picture it state wide! Just how long do you think we'll continue to "feel" the ripple from this well planned tidal wave? Where will that ripple be most felt? 
How can this be best managed? Word to all the wise guys...think it through to the end. Change is not something we want to happen in such a rush we kill the very people we intend to help.


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## Melclin (Oct 5, 2009)

rescue99 said:


> I don't "feel" maintaining the same lower standards is the answer. If you read more than on surface, I said yes, requirements must increase but, we have to be realistic. This is the U.S. and we do have complex layers to our massive public safety, education and  health care systems. We cannot simply change on a dime. It takes years to implement each phase and years to acclimate to them. To do anything else would cause huge gaping holes to form and patients would be the ones falling through the cracks. Aussie might be happy but patients are the first concern here. Let me give an example;
> 
> These past 12 months (3 semesters) we've changed our pre-reqs for all levels of our EMS program at the college. Entry now requires Bio, Med Term, A/P and Pharm, no matter which level. Entry into Medic also requires a Basic EMT license. Change is fantastic but, it means enrollment for the EMS programs went down by 75% and it stayed that way until, well, it's still down! Enrollment will continue to stay low for another 2 semesters while incoming students meet the new requirements for entry.
> 
> ...



You're quite right. Change leaves holes. Of all kinds (see bellow). I don't for a moment believe that you could up and change everything you have now to a completely different system. It was just a comment the focus of you education, the all or nothing nature of it - not practical advice on what I think you should do.

When we made the jump from advanced diploma (2 years, technical school type education), to bachelors degree (3 years, and taught as a university subject) the adjustment of the curriculum, meant that we churned out a lot of dodgy medics who were failed by the fledgling degree. A fact for which the state service is now paying. Still you can't hold back on necessary progress just because they'll be a few bumps. But I'm not telling you anything thing you don't know already.


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## MrBrown (Oct 5, 2009)

Melclin said:


> Brown, how is the 911/IFT divided over your way?...



All services here hold a contract for both emergency and IFT.  To be a PTO (Patient Transport Officer) you need to do a four week course and then you're good to go.

The scope of practice is horrendous - O2, AED and I think maybe entonox but you are really a glorified taxi driver to bring in extra revenue.  It is expected that you would call for backup from a road crew in the event you required any form of medical intervention beyond the very, very basic as if your patient is at risk of requiring a higher skill level they don't meet the criteria for a PTO vehicle.

Some transfer trucks do have Techs (BLS) but thats it; if you are a Paramedic or higher you are not allowed to work on a transfer truck.  There is also an expectation that a transfer truck would *never* get sent to an emergency but we've had one or two come across an MVA for example.

Interestingly a lot of PTS guys are ex Paramedics and Intensive Care Paramedics who don't want to work emergency anymore so they probably have more experience than some of our Intensive Care Paramedics!


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## triemal04 (Oct 5, 2009)

rescue99 said:


> Absolutely not! The Basic EMT is THE primary transfer care provider serving several million of our infermied and elderly each year in the U.S. The wage ceiling will never support the sort of requirements proposed here. EMT is a such a vital part of our EMS system. We have to make it attractive because there is a revenue ceiling, period. The overhead cost of using Paramedics to do basic back and forth calls all day, everyday largely outweighs the need to increase education demands, period.....so we wait! Wait for what? That's a whole other can of worms best left alone. The debate would raise the roof!


Sort of.  It's not so much that EMT's (by that I mean basics) are such a vital part, it's that things are included in EMS that shouldn't be (NETS; non-emergency transport services; dialysis runs, hospital to home transfers) and, as far as I know, medicare does not recognize anything lower than an EMT, like a first responder.  The majority of transfers would do fine with someone with less training than an EMT, but there isn't any recognized national level that can get reimbursement.  So the EMT has to be used, which would create problems if the educational level was increased.  A better solution would be to increase the education, reform medicare so that services could still get reimbursement even if an EMT wasn't used (for certain situations) and allow first responders to pick up the slack.  But that would take a HUGE amount of effort from a lot of people.


rescue99 said:


> These past 12 months (3 semesters) we've changed our pre-reqs for all levels of our EMS program at the college. Entry now requires Bio, Med Term, A/P and Pharm, no matter which level. Entry into Medic also requires a Basic EMT license. Change is fantastic but, it means enrollment for the EMS programs went down by 75% and it stayed that way until, well, it's still down! Enrollment will continue to stay low for another 2 semesters while incoming students meet the new requirements for entry. .


Out of curiosity, has the administration looked at the number of people now enrolled in the prereq classes?  Is it just a temporary decline, or are people saying screw it and going somewhere that doesn't require the extra education?  I applaud what you guys did, and it should be mandatory everywhere, but, I'm unfortunately going to guess that you're running into what happens when one school increases the requirements while the rest don't.  Nutz.


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## rescue99 (Oct 6, 2009)

triemal04 said:


> Sort of.  It's not so much that EMT's (by that I mean basics) are such a vital part, it's that things are included in EMS that shouldn't be (NETS; non-emergency transport services; dialysis runs, hospital to home transfers) and, as far as I know, medicare does not recognize anything lower than an EMT, like a first responder.  The majority of transfers would do fine with someone with less training than an EMT, but there isn't any recognized national level that can get reimbursement.  So the EMT has to be used, which would create problems if the educational level was increased.  A better solution would be to increase the education, reform medicare so that services could still get reimbursement even if an EMT wasn't used (for certain situations) and allow first responders to pick up the slack.  But that would take a HUGE amount of effort from a lot of people.
> 
> Out of curiosity, has the administration looked at the number of people now enrolled in the prereq classes?  Is it just a temporary decline, or are people saying screw it and going somewhere that doesn't require the extra education?  I applaud what you guys did, and it should be mandatory everywhere, but, I'm unfortunately going to guess that you're running into what happens when one school increases the requirements while the rest don't.  Nutz.



Enrollment is way up in the new pre-reqs and it will balance out over the next couple of years. Probably a dozen new A/P courses have been added at the college to accommodate the enrollment increase. I assume the other pre-reqs are the same. Those classes are filled to the brim! A very good thing! By winter semester we should see fuller EMS classes better prepared.  

As I remember, when we went through the last big changes they started in 95 but, only a few schools went the extra mile in really improving education before officially implementing NR 2000. The result was a mix of old and new which left us with a fairly wide disparity in the quality of Medics that seemed never ending. Plus, the area was plagued with a 3 year shortage of Medics. Some schools caught up and others never really have. 

It's all about to change and the good news is, it will include Basic, Spec and Medic.


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## triemal04 (Oct 6, 2009)

rescue99 said:


> Enrollment is way up in the new pre-reqs and it will balance out over the next couple of years. Probably a dozen new A/P courses have been added at the college to accommodate the enrollment increase. I assume the other pre-reqs are the same. Those classes are filled to the brim! A very good thing! By winter semester we should see fuller EMS classes better prepared.
> 
> As I remember, when we went through the last big changes they started in 95 but, only a few schools went the extra mile in really improving education before officially implementing NR 2000. The result was a mix of old and new which left us with a fairly wide disparity in the quality of Medics that seemed never ending. Plus, the area was plagued with a 3 year shortage of Medics. Some schools caught up and others never really have.
> 
> It's all about to change and the good news is, it will include Basic, Spec and Medic.


That's great.  Is it just your college that's doing this, or is it more widespread in Michigan?


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## rescue99 (Oct 6, 2009)

Pretty much all of the colleges are now doing the same. Some of the free standings are also jumping on board. If the plan goes well, in a decade they'll all be up to par. Time will tell.


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## Summit (Oct 6, 2009)

*Rescue 99*: most interesting... you say most schools in your area are now asking for A&P before EMT? That definitely has not been implemented here nor have I heard any noise of it in my program. It would be good though.

*MrBrown*: Very similar to something I posted in 2005

The 72 hour AS degree EMT



			
				Summit said:
			
		

> Semester I
> English Comp I 3hr
> College Algebra 4hr or Statistics 3hr
> Biology I /w lab 5hr
> ...


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## rescue99 (Oct 6, 2009)

Summit said:


> *Rescue 99*: most interesting... you say most schools in your area are now asking for A&P before EMT? That definitely has not been implemented here nor have I heard any noise of it in my program. It would be good though.



Most colleges are yes, Summit. We startred out with Spec and Basic having to do A/P and Med Term as a co-reqs at first. Bio is already a pre-req for A/P and Pharm was just added this semester. I know of a couple of free standing schools that are also making A/P and Med Term.  part of their requirements now too in the past year. Things are definately looking up.


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