# Urgent care on wheels



## MagicTyler (Jan 23, 2013)

> For the past six months, a Mesa Fire Captain has been teamed up with a nurse practitioner to respond to low-level emergencies.
> 
> The idea is to treat people on the scene so they don't have to go to the ER. They're even writing prescriptions, almost like a primary care provider.
> 
> It looks like just another ambulance, but think of this more like an "urgent care" on wheels.




http://www.myfoxphoenix.com/story/20663693/urgent-care-on-wheels


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## Shishkabob (Jan 23, 2013)

We knew it was going to happen... nurses trying to catch the wave on community paramedicine with the explanation "But we can write prescriptions!"


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## JPINFV (Jan 23, 2013)

"almost like a primary care provider."

Today's SAT analogy...

EMT-Isaramedics::some mid-levelshysicians.


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## EpiEMS (Jan 23, 2013)

...my brain...ow. This is a good concept, but I don't like how it was executed. I'd much rather see a community/advanced practice paramedic in a Charger than an ambulance (a la Wake County). Or, failing that, an assistant medical director who's a PA (and can respond to calls on top of doing this community medicine role). Granted, I'm not such a huge fan of the NP over the PA (considering the different training models, varying laws regarding supervision, etc.).

Also...if this anecdote is representative of what the NP is doing: "I'm going to get some vital signs -- I'm going to get some ice back there -- and I'm going to get you something for pain okay? Sound good? Right on."

So, it's a pain med delivery service...? [Update: as per http://www.azsos.gov/public_services/Title_04/4-19.htm#pgfId-36529 and http://www.azbn.gov/documents/advis...iption of Role and Functions rev Jan 2009.pdf NPs in AZ can prescribe up through Schedule II drugs, and they don't have physician chart review)


(By the way, JP, they got rid of analogies on the SAT -- crazy, right?)


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## JPINFV (Jan 23, 2013)

EpiEMS said:


> (By the way, JP, they got rid of analogies on the SAT -- crazy, right?)



...and my 1240 isn't anything remotely decent anymore either.


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## EpiEMS (Jan 23, 2013)

JPINFV said:


> ...and my 1240 isn't anything remotely decent anymore either.



1240/1600 compares to an 1860/2400, ceteris paribus...but a 1240/2400 is just embarrassing


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## Veneficus (Jan 24, 2013)

EpiEMS said:


> 1240/1600 compares to an 1860/2400, ceteris paribus...but a 1240/2400 is just embarrassing



So what? He is still called "doctor."


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## systemet (Jan 24, 2013)

Linuss said:


> We knew it was going to happen... nurses trying to catch the wave on community paramedicine with the explanation "But we can write prescriptions!"



I don't see this as a bad thing.  They're better educated for community / primary care, and the NPs have a level of licensure that allows they to prescribe. If they add value, which presumably they do, it might make the fledgling programs that exist now more sustainable.

It would be great to see Master's degree paramedics running around prescribing, but that's a long way off in a lot of countries.  No one's going to give us a 16 hour weekend course, and say, hey, now you can prescribe clarithroymycin.


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## wanderingmedic (Feb 27, 2013)

great idea. only problem I see is nurses having to put up with EMS. I don't know of many nurses who would enjoy working out of a station with EMS or fire. 

I think PA's could be a better option. The national average for PA school is ~26 months, and I have heard of PA programs that are willing to take medics who have an AAS and experience. Not to mention having one Medical Director calling the shots for treatment across a system could standardize treatment, instead of NPs who have their own licenses and can do what they want (to an extent).  PA's are also less specialized than NP's and are more oriented toward primary care and emergency medicine.

This all goes without saying the ed cost for a PA is more financially prudent since your not paying for a 4 year BS, then ~3-4 year doctorate like NP's need to.


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## Clipper1 (Feb 27, 2013)

azemtb255 said:


> PA's are also less specialized than NP's and are more oriented toward primary care and emergency medicine.



That is not entirely true.

NPs do have specialty programs but many are geared for family practice and for community health. The NPs in community health have been prominent in many cities and rural areas for the past 40 years. 

NPs also have the advantage of more often than not having at least 2 years of experience working in a healthcare setting as an RN prior to entering NP school. 

PAs definitely have their place also in community health.

But, if you present this purely on economics and start pushing for someone with just an Associates degree and limited experience primarily in emergent situations rather than someone with a Masters level education, , is the public better served?   This is like saying the 3 month medic mill is better than the 1 year medic certificate or the 2 year degree if you can mass produce for the cheap.

There are several states, including Texas and Virginia, which have had success with NPs in community health units which provide care in mobile units.  The reason some in EMS may not have noticed is that they primarily serve those who are poor and without insurance which does not sound very exciting to EMS or this population is just written off as calls which waste time. The preventative or overall health aspect is missed since that is not the focus of EMS. These community vans will also rarely have a need to call an ambulance since they may have their own connections for transport since they have access to Social Workers to work with them. Working with others in healthcare rather than against them is key to success for any system.  Some in EMS waste more time disregarding others in health care as being unprofessional and unnecessary rather than embracing a team concept. One could say EMS is attempting to fragment other systems just as it has its own.

Fire departments are a good option for providing the transport and space since their facilities and vehicles are tax supported. It can give patients a stationary "clinic" with easy access in most neighborhoods. Most FDs also have CMS billing ability.


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## Clipper1 (Feb 27, 2013)

Linuss said:


> We knew it was going to happen... nurses trying to catch the wave on community paramedicine with the explanation "But we can write prescriptions!"



Nurses have been involved in community medicine for over a century. They have helped with clinics, mobile and stationary, and even have been involved in mobile military units for many wars.  Nurses have increased their education to meet the demands of the community.  The community Paramedic concept had been trialed a couple of decades ago and failed because of the disconnect between EMS and preventative medicine or as some would say the chronics.  I doubt if a 100 hour course in addition to the current Paramedic cert is going to change the mindset for those who entered EMS for the emergencies and not to be glorified snot or butt wipers in a mobile van.  The privilege of writing prescriptions for NPs also comes with remembering how to be a nurse in many situations especially when it comes to working the streets. This does not mean scoop and transport but establishing a care plan for many visits and being good enough to educate for compliance or know the resources which can.  But this again means relying on others for a team effort rather than trying to have a penis measuring contest at the expense of the community.


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## mycrofft (Feb 27, 2013)

I worked as a primary care nurse conducting my own sick call using a 500 plus page standardized procedures manual. I was a former EMT and a baccalaureate prepared licensed RN with such experience in the field (military). I had good access to a MD at all times. At times, I would see _*fifty patients in eight hrs *_(yes), mostly just wanting some Advil or a Rx renewal. 

Worked well with me. We had trouble with other RN's overreaching (inventing their own standardized proceduresw) or not being able to make enough decisions and turfing ALL the pts to the MD.

But without those standardized procedures (MD orders) I would have been virtually motionless. As it was, each successive review made the scope narrower and narrower until we couldn't order sudafed, tinactin, or normal saline eye drops.

Withbout an MD's orders, as protocol or SP or whatever, the nurse cannot do this.


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## Clipper1 (Feb 27, 2013)

systemet said:


> It would be great to see Master's degree paramedics running around prescribing, but that's a long way off in a lot of countries.  No one's going to give us a 16 hour weekend course, and say, hey, now you can prescribe clarithroymycin.



If Paramedics are educated like NPs and PAs in community medicine at the Masters level and working solely in community medicine, would you consider them to be the same as the EMS Paramedics?  What if they only get manikin intubation experience and no longer run 911 calls? Except for the name would they be the same?


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## Summit (Feb 27, 2013)

azemtb255 said:


> great idea. only problem I see is nurses having to put up with EMS. I don't know of many nurses who would enjoy working out of a station with EMS or fire.


I don't know many nurses who want to work with paramedics on critical care transports and helicopters... oh wait... there bunches of em. :rofl:

*Suffice to say, I don't see a PA vs NP problem here for the role.  Both are suited and will self-select according to interest and practice limitations of their locale. *

Sign me up (for the helicopter or the ambulance if I become a midlevel).



azemtb255 said:


> great idea. only problem I see is nurses having to put up with EMS. I don't know of many nurses who would enjoy working out of a station with EMS or fire.
> 
> I think PA's could be a better option. The national average for PA school is ~26 months, and I have heard of PA programs that are willing to take medics who have an AAS and experience. Not to mention having one Medical Director calling the shots for treatment across a system could standardize treatment, instead of NPs who have their own licenses and can do what they want (to an extent).  PA's are also less specialized than NP's and are more oriented toward primary care and emergency medicine.
> 
> This all goes without saying the ed cost for a PA is more financially prudent since your not paying for a 4 year BS, then ~3-4 year doctorate like NP's need to.



Most PA schools in most of the US are MS programs and most PA students have a BS. Most NP programs are MSN programs who accept only BSN RNs and are also 26 months long. DNP programs are optional extensions offered by a great many NP schools.



EpiEMS said:


> 1240/1600 compares to an 1860/2400, ceteris paribus...but a 1240/2400 is just embarrassing



If it is just a straight 3:2 ratio, can I cash in my old 1510 for a 2265? Does that get me a front row seat for my MCAT? :wacko:


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## Summit (Feb 27, 2013)

Echoing Clipper's last two posts, the provider role under discussion has long been the realm of the community health RN/NP. In fact, it bears very little resemblance to EMS and paramedicine. Community medicine really doesn't resemble emergency medicine AS EMS SEES IT (as opposed to how the ED is forced to deal with it). As Clipper points out, the role of a community health whatever is very far from the role EMS providers typically believe they fill (and train for).


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## Clipper1 (Feb 27, 2013)

mycrofft said:


> I worked as a primary care nurse conducting my own sick call using a 500 plus page standardized procedures manual. I was a former EMT and a baccalaureate prepared licensed RN with such experience in the field (military). I had good access to a MD at all times. At times, I would see _*fifty patients in eight hrs *_(yes), mostly just wanting some Advil or a Rx renewal. .



In the military you probably would have a younger population and many of the pre-existing conditions requiring intensive followups would not be accepted in the military. 



> Worked well with me. We had trouble with other RN's overreaching (inventing their own standardized proceduresw) or not being able to make enough decisions and turfing ALL the pts to the MD.



It seems you don't like RNs from this and just reading a few of your recent posts.  An EMT also must turn their patients over to MDs.  Your ego as an EMT might get you into trouble if you believe you can do it all without referring to a doctor.  The original discussion concerns NPs and PAs. NPs are RNs who continue their education to a BSN and then a Masters level.  Unless you have an understanding of the education and scope of practice for other professionals, it is really not appropriate for you to make such comments just in an attempt to make RNs look stupid. 



> But without those standardized procedures (MD orders) I would have been virtually motionless. As it was, each successive review made the scope narrower and narrower until we couldn't order sudafed, tinactin, or normal saline eye drops.
> 
> Withbout an MD's orders, as protocol or SP or whatever, the nurse cannot do this.






EMTs and Paramedics also can not do anything without protocols from a doctor. If you compare RNs to Paramedics you will find the RN's scope of practice can easily be expanded.  But still the discussion is about NPs and PAs in the community.  That doesn't mean there are  not RNs and many other HCWs involved in the needs of patients outside of the hospital  

The distinction between what prehospital care as EMS sees it and what out of hospital care actually consists of.  Not everything is an emergency. But, that does not mean not everything will be within a Paramedic's ability to diagnose and treat for a treat and release program. Only a few things are acute and obvious. Most disease process will require an advanced practitioner. There is also nothing wrong with referring to a doctor and even one who is a specialist. Doctors also refer to each other and do consults.  NPs and PAs do have the knowledge to know when they are in over their abilities. Some with lessor training believe they can do it all because they don't know how much they don't know.


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## JPINFV (Feb 27, 2013)

Clipper1 said:


> An EMT also must turn their patients over to MDs.










...because an EMT transferring care to a physician and a mid-level transferring care to a physician is completely the same thing. At the current situation, one is expected to be competent at treating and releasing within a certain population of patients. The other isn't. Where's the efficiency if the mid-level is going to triage a significant number of patients to a physician anyways? So we get to pay for a trip to the mid-level AND a trip to the physician? After all, fiscal efficiency is the only reason mid-levels exist.


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## wanderingmedic (Feb 27, 2013)

Summit said:


> Most PA schools in most of the US are MS programs and most PA students have a BS. Most NP programs are MSN programs who accept only BSN RNs and are also 26 months long. DNP programs are optional extensions offered by a great many NP schools.



Nursing is moving towards a DNP as the standard for nurse practitioners. The MSN programs for NP's are bring phased out and any current MS NP's are being grandfathered in.


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## Amberlamps916 (Feb 27, 2013)

JPINFV said:


> ...and my 1240 isn't anything remotely decent anymore either.



Dude, I thought my 1210/1600 was nothing to get excited about. I farted around during and after high school anyway so I never took advantage of that score. Now I'll end up being a transfer student from a jc. Still debating if I should follow my grandparent's footsteps (they were both general surgeons and my grandfather taught at The Royal College of Surgeons of Edinburgh, Scotland) and take the plunge into medical school or take the much maligned PA route. Decisions, decisions.


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## Summit (Feb 28, 2013)

azemtb255 said:


> Nursing is moving towards a DNP as the standard for nurse practitioners. The MSN programs for NP's are bring phased out and any current MS NP's are being grandfathered in.



This rumor is most persistent... usually it is accompanied with the "DNP entry by 2015" canard. That is what some want to see, it is a trend but it is NOT what is happening with any speed.

Once nursing academia adds universally stipulates that the DNP expansion has to have more clinically meaningful content, it will gain traction. That is only the case in some programs, thus plenty of schools and students continue to pass on it.


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## VFlutter (Feb 28, 2013)

Clipper1 said:


> It seems you don't like RNs from this and just reading a few of your recent posts.  An EMT also must turn their patients over to MDs.  Your ego as an EMT might get you into trouble if you believe you can do it all without referring to a doctor.  The original discussion concerns NPs and PAs. NPs are RNs who continue their education to a BSN and then a Masters level.  Unless you have an understanding of the education and scope of practice for other professionals, it is really not appropriate for you to make such comments just in an attempt to make RNs look stupid.



It is really not appropriate for you to make such an assumption about him or his "ego as an EMT'. You are new to this forum so I understand you are no familiar with many of our regular posters but I will let you in on a little secret.... He was an RN.


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## MediMike (Feb 28, 2013)

Hahaha...that's happened a couple times.  Was confused about Vene and JP as well...it'll come to him eventually.


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## medichopeful (Feb 28, 2013)

Chase said:


> It is really not appropriate for you to make such an assumption about him or his "ego as an EMT'. You are new to this forum so I understand you are no familiar with many of our regular posters but I will let you in on a little secret.... He was an RN.



Which he mentioned in his post that Clipper didn't particularly like :wacko::



mycrofft said:


> I worked as a primary care nurse conducting my own sick call using a 500 plus page standardized procedures manual. I was a former EMT and a baccalaureate prepared licensed RN with such experience in the field (military).


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## Clipper1 (Feb 28, 2013)

Chase said:


> It is really not appropriate for you to make such an assumption about him or his "ego as an EMT'. You are new to this forum so I understand you are no familiar with many of our regular posters but I will let you in on a little secret.... He was an RN.



He talked more about his abilities as an EMT. He also demonstrated very little understanding about RNs and what they can or can not do. From reading his other posts he hates being an RN and wishes to be an EMT.  He makes a point of showing RNs as inferior and poorly trained to make any decisions. That you can read for yourself in his posts.


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## Clipper1 (Feb 28, 2013)

JPINFV said:


> ...because an EMT transferring care to a physician and a mid-level transferring care to a physician is completely the same thing. At the current situation, one is expected to be competent at treating and releasing within a certain population of patients. The other isn't. Where's the efficiency if the mid-level is going to triage a significant number of patients to a physician anyways? So we get to pay for a trip to the mid-level AND a trip to the physician? After all, fiscal efficiency is the only reason mid-levels exist.



No. An EMT is not a mid level provider. They do not have anywhere near the same level of education. They do not have the same abilities when it comes to triage and ordering or prescribing.  Do you really want EMTs to take the place of NPs in the health care system? What training do they have in diseases, labs, pediatrics or geriatrics?  

I understand you are passionate about being an EMT but you must realize that there is alot more to medicine and the over all health care process which an EMT is limited by education and scope.  EMT is an entry level provider.

There is really alot of hate for RNs, NPs and PAs on this forum. It seems that many EMTs do not get enough exposure to other professions. It also appears that know about CMS, insurances, budgets, health care costs and regulatory boards are not clearly understood either.


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## Clipper1 (Feb 28, 2013)

medichopeful said:


> Which he mentioned in his post that Clipper didn't particularly like :wacko::




He might be an RN but his posts also say he is more of an EMT.  His own personal preference with a known dislike of nursing should not be a cause to misrepresent what all RNs can and can not do.  If he does not like being an RN then he shouldn't be one.


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## JPINFV (Feb 28, 2013)

Clipper1 said:


> No. An EMT is not a mid level provider.


 I never said they were the same. Do you want to try wacking that straw man again?



> I understand you are passionate about being an EMT but you must realize that there is alot more to medicine and the over all health care process which an EMT is limited by education and scope. EMT is an entry level provider.


 
Actually, since I guess you missed my earlier post... I'm a 3rd year medical student. Want to try again?


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## Clipper1 (Feb 28, 2013)

JPINFV said:


> I never said they were the same. Do you want to try wacking that straw man again?
> 
> 
> 
> Actually, since I guess you missed my earlier post... I'm a 3rd year medical student. Want to try again?



 You post more in suport of EMT-Bs on an EMT forum. There is nothing to indicate your level of education is that of a 3rd year medical student.  Have you been in any clinical situation yet where there is interaction with other health care professionals? I know in one reply to me you assumed a doctor was looking only at SpO2 on a child. A doctor or even a 3rd year MS should realize one might be analyzing all data rather than just taking one number into consideration. By not pointing out there is much more, you really are not doing EMTs a favor by leading them to believe medicine is so simple not further education is needed.  If you are an MS3, don't be afraid to utilize or show what you have learned.  At some point you will have to stop relying on being an EMT and move forward.  Of course not all med schools are created equal but not knowing you or your school, I only have your posts to go by.  Does your med school teach this dislike for midlevel practitioners or is this the EMT in you talking?


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## JPINFV (Feb 28, 2013)

Clipper1 said:


> You post more in suport of EMT-Bs on an EMT forum.


Really? Where? You're not really too familiar with my posting history if you think I show some sort of unwavering support for EMTs and paramedics. 



> There is nothing to indicate your level of education is that of a 3rd year medical student.


Except the entire "OMS-III" part of my training. The "MS" stands for "master of science" since I graduated from a masters program prior to medical school. Of course we know nothing about your background.


> Have you been in any clinical situation yet where there is interaction with other health care professionals?


Every single day. 


> I know in one reply to me you assumed a doctor was looking only at SpO2 on a child.


No. I said that supplemental oxygen in a patient diagnosed with lower airway inflammation (bronchiolitis) secondary to a viral infection (RSV) was being done based off of clinical exam and oxygen saturation. You were the one who was calling for blood gasses and a VQ scan. However I guess that doesn't work with your narritive, hence why you still haven't replied in that thread.



> If you are an MS3, don't be afraid to utilize or show what you have learned. At some point you will have to stop relying on being an EMT and move forward.


Again.. you're not too familiar with my posting history apparently. 



> Of course not all med schools are created equal but not knowing you or your school, I only have your posts to go by. Does your med school teach this dislike for midlevel practitioners or is this the EMT in you talking?


 

Cute. You want to judge my medical school? On what merit do you plan on judging them.

Also, I love how apparently suggesting that mid-levels are gods of medical care with no limits to their ability means that, somehow, I have a "dislike" of midlevels. Just as much as you want EMTs to know their limitations, is there something wrong with wanting midlevels to know their limitations?


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## Summit (Feb 28, 2013)

Clipper. Chill out. It is the internet. There are definitely some people on the forum who aren't kind to midlevels and RNs, but stop putting your crosshairs on anyone in your path including RNs. Let's get back to the topic at hand.


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## ffemt8978 (Feb 28, 2013)

Summit said:


> Clipper. Chill out. It is the internet. There are definitely some people on the forum who aren't kind to midlevels and RNs, but stop putting your crosshairs on anyone in your path including RNs. Let's get back to the topic at hand.



Yeah, that.


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## mycrofft (Feb 28, 2013)

Just woke up from my nap. Did I miss anything?

Clip, my thumbnail CV: First aid/lifeguard 1972; firefighter 1975-79; EMT 1977-84; Air Nat Guard med tech 1980-1987; RN 1983-present (BSN); Air Nat Guard nurse 1987-1997. Nurse sick call was in a County correctional setting, field medical support for Guard was 1985-1997. CERT vollunteer  active 2007-2012.

I bake a mean sourdough bread and like cats AND dogs.


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## Clipper1 (Feb 28, 2013)

JPINFV said:


> Really? Where? You're not really too familiar with my posting history if you think I show some sort of unwavering support for EMTs and paramedics.
> 
> 
> Except the entire "OMS-III" part of my training. The "MS" stands for "master of science" since I graduated from a masters program prior to medical school. Of course we know nothing about your background.  *(Osteopathic Medical Student? Around here and in more teaching hospitals MS is med student. You will learn this if you get into clinical situations. )*
> ...




Gods of medical care?  I do prefer an NP or PA to be in charge of a clinic for medical care with involves non emergent treatment, long term care and preventative medicine over an EMT or Paramedic.  To say there is not a place for NPs or PAs is just very short sighted on your part.

Bloods gases and V/Q Scan?  Where did you get thAt from? I will repeat that a knowledge of the disease process will determine overall treatment and weaning protocols.  A V/Q Scan is not necessary in this situation. You might want to review the indications for a V/Q Scan. ABGs may or may not be necessary also since it is likely a CXR (Chest X-Ray) was done. A CMP or CBC was probably done which would have indicated the type of infection or inflammatory response.  You did state you did not know what type of workup was done. 

My knowledge of your previous posts comes from here.

http://www.emtlife.com/search.php?searchid=3332948


I don't reply to every response nor do I look at this website very often. It seems this forum is a closed discussion to only a few. The VAP posts were brought to my attention by an EMT in the ED who gets a kick out of showing us what EMTs and Paramedics think of nurses and PAs.  It definitely sets the tone around here when we know how we are viewed by EMTs and Paramedics in public.  

#########################

For the person from King County, I invite you to join us on the discussion forums at SCCM.  We welcome any professional who is interested in advancing patient care.  I also suggest to those interested in a more informed discussion complete with references that they should join a professional group with a closed member access. Names and workplaces can be freely disclosed since they are a requirement for entrance.  These are great places for networking.  I have heard EMS has a few organizations like that which EMTs and Paramedics can join.


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## Veneficus (Feb 28, 2013)

Clipper1 said:


> I also suggest to those interested in a more informed discussion complete with references that they should join a professional group with a closed member access.



Did that.

Drs. Only. Credentials verified. Doesn't work out so well though, like all internet forums, there seems to be a core group that dominates discussion and while everyone is invited to join, participation is somewhat more reserved.

I used to belong to a mixed professional forum when I was a medic. However, the constant berating I got from PAs "with much more medical education" got old fast. 

They don't seem to like it too much now that I turned that table.

EMTs and Medics aren't actually welcomed many places. They are simply tolerated or given a seat at the childrens table. 

Go to a trauma conference and see the difference in the breakout sessions for doctors and medics. It is like not even being in the same hotel. 



Clipper1 said:


> Names and workplaces can be freely disclosed since they are a requirement for entrance.



People I trust know who I am. Just because a person discloses their name and workplace doesn't mean they are not psycho.

disingenious Jake.


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## JPINFV (Feb 28, 2013)

...and since Clipper keeps lying out her teeth about my posts (hint: I did say I know the workup... I have access to the EMR) and making strawmen so large that it could be a wonder of the modern world, she's joined the very very small list (now 4) known as my ignore list.


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## NomadicMedic (Feb 28, 2013)

Last warning to keep this thread on topic.


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## Carlos Danger (Feb 28, 2013)

Summit said:


> Echoing Clipper's last two posts, *the provider role under discussion has long been the realm of the community health RN/NP. *
> 
> *In fact, it bears very little resemblance to EMS and paramedicine.*
> 
> *Community medicine really doesn't resemble emergency medicine AS EMS SEES IT* (as opposed to how the ED is forced to deal with it). As Clipper points out, the role of a community health whatever is very far from the role EMS providers typically believe they fill (and train for).



This.

Community health has long been the purview of nursing.

I don't see any reason why EMS couldn't get involved, but I don't see it happening in the way and on the scale that many of it's advocates seem to want.

I wrote a long and detailed post about why in the last thread on the topic of community health paramedicine. 

Mostly I think the challenges would come down to problems with licensure and the feasibility of getting universities to design the educational programs on a large scale.


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## Carlos Danger (Feb 28, 2013)

Metro Medical

Unfortunately, I just don't see much role for paramedics in services such as this. 

Not that they couldn't do it with the right education, but NP's and PA's already exist....


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## Summit (Feb 28, 2013)

old school said:


> Metro Medical
> 
> Unfortunately, I just don't see much role for paramedics in services such as this.
> 
> Not that they couldn't do it with the right education, but NP's and PA's already exist....



Indeed, and why the push for the lateral move anyway? Push up before you spread out. I think it is as simple as the mindset of, "outside the hospital is prehospital medicine no matter what is actually happening and prehospital medicine is EMS. PA school is too much, so lets make a some super-duper medics, and call it good." This isn't logical, especially when matched against what frequently is said in threads with non-turf-war themes: that non-acute patients are a waste of EMS resources.


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## JPINFV (Feb 28, 2013)

Summit said:


> Indeed, and why the push for the lateral move anyway? Push up before you spread out. I think it is as simple as the mindset of, "outside the hospital is prehospital medicine no matter what is actually happening and prehospital medicine is EMS. PA school is too much, so lets make a some super-duper medics, and call it good." This isn't logical, especially when matched against what frequently is said in threads with non-turf-war themes: that non-acute patients are a waste of EMS resources.




The problem, as I see it, is the large number of people who are calling 911 for chronic health needs. As such, it's not necessarily that EMS is best suited or the best enterprise to provide home health. It's that it's being accessed in that manner regardless and at expense to the system as a whole. The option is to either adapt to the current demands being placed on the system, or be run over by an out of control system. 

Emergency departments aren't the best suited for patients with chronic primary care diseases either. However, imagine if emergency physicians suddenly said "screw this, we aren't PCPs. That new onset HTN that isn't up to urgency/emergency standards? Go away. Med refill? Go away." The healthcare system would collapse overnight. It's not that they want to do it... it's that the system demands that they do it.


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## Summit (Mar 1, 2013)

JP: I agree with that, as I mentioned how EMS perceives emergency medicine is far different than "how the ED is forced to deal with" the real patient load.

My last comment was mostly regarding a common theme of cognitive dissonance in EMS when faced with non-acute patients versus when faced with perceived turf battles.


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## Veneficus (Mar 1, 2013)

*EMS and the primary care turf war*

I think there are 2 issues in play here.

1. I think primary care is an outdated medical modality. The way it is set up and functions does not serve the population very well. As such, the ED has become the entrance to the medical system.

The ED is not set up for, nor optimal for this population. Not to mention it is wickedly expensive.

You can flood a system with primary care, but if it doesn't work for people, it won't matter how much of not working you have.

2. Prevention vs. response. 

The amount of people requesting EMS or rather the amount of the same people request EMS is so great that a response only system is only going to be overwhelmed. (which we see everyday in the US) 

In order to resolve this system overload, some type of prevention or pre-emptive response is going to be required. 

Whether or not EMS is ideal for it doesn't change that EMS is currently best positioned for it. 

Other providers, no matter what level, have basically excluded themselves from this mission based on current reimbursement and legal realities. 

But that doesn't address the need.

As such, the goal of community paramedicine is to save money ad reduce response in an ineffective system. Undoubtably nurses or others are better educated and would provide a higher level of healthcare. 

But they are not going to do it for the price of a paramedic. These "advanced" providers have basically priced themselves out of the market. 

You can brag about the superior performance of sports cars all you like, but when all you have is the budget for economy, the performance measure is moot.


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## Summit (Mar 1, 2013)

Veneficus said:


> As such, the goal of community paramedicine is to save money ad reduce response in an ineffective system. Undoubtably nurses or others are better educated and would provide a higher level of healthcare.
> 
> But they are not going to do it for the price of a paramedic. These "advanced" providers have basically priced themselves out of the market.



Should it be done for the price of a paramedic? Not if the price justifies more care. We've already discussed that two medics and an E450 ambulance is pricier than a nurse, NP/PA, or even a physician in a Toyota Corolla.

The success of CPs seems grand if you go with, for example, the ECAD program of "Free CP visits. Free. FREE! CALL US WHENEVER! REALLY! NO CHARGE!" But is that viable?

Of course RN, midlevel, and physician as a mobile community health provider would each offer a (variable) increase in level of care at increasing cost. What makes sense?

I think having all of those providers in the program makes sense! My BSN RN/midlevel/physician in a Toyota is reality:

I'll point to a long running viable program with a track record of success (that I bet nobody here has heard of). That is, the VHA Home Based Primary Care (HBPC) program. “HBPC is comprehensive, longitudinal primary care provided by a physician-supervised interdisciplinary team of VA staff in the homes of veterans with complex, chronic, disabling disease for whom routine clinic-based care is not effective. “ It was started in 1970, originally as a palliative and primary care program. In quickly grew into a proactive community health program for qualified veterans with the goals of increasing care while decreasing cost. Increased care (and qualifications) comes by targeting it at known disadvantaged veteran populations, particularly those who are unable to travel to care. Decreased cost comes through preventative care that has demonstrably decreased both hospital admissions, lengths of stay, acuity, and non-institutionalization in the HBPC patient population. 

The HBPC program is actually multi-discipline with RN/NP initial assessments, physician referral, RN/NP follow up (depending on disposition), and referral to RD, psychology, and OT as necessary. This program is aimed at preventing exacerbations of chronic conditions through monitoring, education, assessment, medication refills, all of which could lead to 911 calls and in-patient stays, or institutionalization in a ALF/LTC. The program has demonstrated better outcomes for the veterans served by it and a cost savings to the VA institution. The only thing stopping a similar model from being applied to the general public is a lack of will.


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## Veneficus (Mar 1, 2013)

Summit said:


> Should it be done for the price of a paramedic? Not if the price justifies more care. We've already discussed that two medics and an E450 ambulance is pricier than a nurse, NP/PA, or even a physician in a Toyota Corolla.



Yes, that is true, but it is not so easily compared. When you have 2 medics and an ambulance and you add other resources, it is not cheaper. 

I wouldn't say the medic model really has the goal of adding care, but primarily to reduce the needfor emergency care, thereby lowering call volumes. That is where the money is saved, not earned.

It basically gives already existing response persons work to do when not responding to prevent calls and thereby allow for less response resources.

I think home healthcare (from all disciplines) is absolutely vital for effective primary care. But as I said, the current primary care system in the US doesn't work, and other countries who use the same model are seeing it stressed or ineffective.

Medical practice must evolve with society in order to maintain value, it doesn't. 



Summit said:


> The success of CPs seems grand if you go with, for example, the ECAD program of "Free CP visits. Free. FREE! CALL US WHENEVER! REALLY! NO CHARGE!" But is that viable?



Depends...

It will not be self supporting. The money will likely have to come from some form of tax somewhere.

However, not charging a patient for any medical service out of pocket maintains that person's wealth. Which maintains the maximum level of independance without additional support. That prevents asset liquidation for medical care, reatains large assets like homes, which can be passed on to family and friends, so their productive years grow wealth instead of needing to replace it. Wealthy societies require less medicine. It is an interesting economic circle.

In the short and direct term, is having a paramedic or two that on down time drives around installing fall precautions, making sure medications are refilled, and the patient understands and is taking them correctly (the later being a core nursing role currently unfulfilled except for a minority of peopl who "qualify" for this.) cheaper?

An example I like to use, paramedic A knows there is an elderly lady in his response area. (it is always a lady cause the men die years before) This medic has been to the house many times, the lady cannot reliably go to appointments, get to the store, etc. Perhaps she has live in family, perhaps not, doesn't matter.

So once a month she goes into acute CHF exacerbation. This known, baseline, call volume adds the need for more ambulances in the area. (costs $) The ALS ambulance to the ED, ICU admit, and day or two in the ward. (costs a lot of $)

How much would be saved having the paramedic and partner stop by during lower call volumes and maybe bring her $3 of lasix with them. Not that they prescribed, but are simply picking up from the pharmacy like any other friend or family memeber. (thousands of $ a month on 1 person)

Let's say you just plan to liquidate her lifetime middle class assets. (much greater than poor or working poor) put her in an SNF, and she lives 20 more years. Her assets will never cover that cost. In a healthcare environment, she will be sick more often, additional treatment and costs. Over those 20 years, even spending everything she has, somebody (aka tax payers) will be on the hook for 10's of thousands if not 100's of thousands. 

Leaving her family to work to reproduce such assets from 0, when they are elderly, this cycle of heavy $ loss repeats. 

If her family were wealthier, they would get sick less often, lss severe, maybe have money for healthy food, less destructive outlets (drinking and smoking) and time to exercise. Further reducing healthcare expenditure over time. (it is not individual, once these people are out of the workforce, they become medicare/medicade) when that is an MI at 50 or COPD at 50 instead of osteoporosis at 80 or 90, you add decades of tax funded healthcare costs.

Does free community paramedicine sound more viable?   

It certainly does to me.




Summit said:


> Of course RN, midlevel, and physician as a mobile community health provider would each offer a (variable) increase in level of care at increasing cost. What makes sense?



Yes it would. to the immediate population, and as I said, ultimately I think to maintain value to society. 

But the short term reality is that it is simply too expensive to implement.



Summit said:


> I think having all of those providers in the program makes sense! My BSN RN/midlevel/physician in a Toyota is reality:



It happens all over the world. 

The thing is though that the VA system is seperate from the overall US system and operates under different rules, with a different population, and a different economic reality. It is not part of the general healthcare market. 

The general healthcare market in the US would benefit from many of the VA ways of doing things. But somebody would have to pay. Additionally, there are many very wealthy and powerful competing interests who stand to lose a lot if those changes are implemented. They will not go down without a fight for their life.


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## abckidsmom (Mar 1, 2013)

The trouble with what you're saying, Vene, is that it's boring. People don't get into EMS because they want to go around helping people have a good plan for taking their meds. Nor to scan the houses for throw rugs or smoke alarms. 

They want to *save lives*, dangit! And what you are suggesting is just lame! /sarcasm. 

In all the medics I have ever known, I can think of less than a dozen who would happily let that be their job forever.


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## Veneficus (Mar 1, 2013)

abckidsmom said:


> The trouble with what you're saying, Vene, is that it's boring. People don't get into EMS because they want to go around helping people have a good plan for taking their meds. Nor to scan the houses for throw rugs or smoke alarms.
> 
> They want to *save lives*, dangit! And what you are suggesting is just lame! /sarcasm.
> 
> In all the medics I have ever known, I can think of less than a dozen who would happily let that be their job forever.



That has been my experience also.

But here is something to think about:

Have you ever heard a frefighter suggest not giving out free smoke detectors or doing fire inspections so they can have more exciting calls and save more lives?

Have you ever heard a LEO suggest not patrolling, writing tickets for speeding, dui, etc. Have you ever heard of LEO wanting to scrap DARE programs so they can make more drug arrests?

Military medics, do you spend more time in life and death combat saves or handing out 800mg motrin and antibiotics?

Who do these paramedics think they are that they are only around to save lives? What feeble skills do they think they have to do it?


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## Wheel (Mar 1, 2013)

abckidsmom said:


> The trouble with what you're saying, Vene, is that it's boring. People don't get into EMS because they want to go around helping people have a good plan for taking their meds. Nor to scan the houses for throw rugs or smoke alarms.
> 
> They want to *save lives*, dangit! And what you are suggesting is just lame! /sarcasm.
> 
> In all the medics I have ever known, I can think of less than a dozen who would happily let that be their job forever.



This is the reason I think so many medics burn out. They expect the life saving, but the vast majority of what we do is far from it. I think if paramedicine wants to survive (or thrive) then they need to embrace this population. We are already responding to these calls, and will continue to for the foreseeable future. Community health RNs are wonderful, but the fact is that people still call 911 for primary care complaints, so I think it's our duty to tailor our education and response to better serve our patient population. I doubt anyone would argue with that.


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## Summit (Mar 1, 2013)

Veneficus said:


> In the short and direct term, is having a paramedic or two that on down time drives around installing fall precautions, making sure medications are refilled, and the patient understands and is taking them correctly (the later being a core nursing role currently unfulfilled except for a minority of peopl who "qualify" for this.) cheaper?


Whenever they aren't busy is like pissin on a fire. Even if we don't talk about which is better, which is easier? Improving availability for home based primary care and home health nursing? Or expanding paramedics to non-EMS roles?





> How much would be saved having the paramedic and partner stop by during lower call volumes and maybe bring her $3 of lasix with them. Not that they prescribed, but are simply picking up from the pharmacy like any other friend or family memeber. (thousands of $ a month on 1 person)


Again it comes to the insanely broken nature of primary care... why the hell is the system so broken that we need to put a parabandaid on it and want to call it an acceptable solution?

I guess the real question is, how about that downtime? Are those paramedics out of service when they are half through her med box and a 911 tones out for their area? We know the truth about response times, but when grandma Phyllis strokes out and it take the medics 5 minutes longer to respond because they had to extricate themselves from their "downtime duties" in aunt Florences medicine bin, someone is going to complain, or sue, etc because perception is reality.



> Does free community paramedicine sound more viable?


 Sure. So doees free community nursing. Except the CHRNs got into the field to fulfill that exact role, not have it be "slow duty."



> The thing is though that the VA system is seperate from the overall US system and operates under different rules, with a different population, and a different economic reality. It is not part of the general healthcare market.
> 
> The general healthcare market in the US would benefit from many of the VA ways of doing things. But somebody would have to pay.


 If we are talking about altering the national or regional health system models with bandaids like CP, and we are talking about paying for free CPs (like the grant funded ECAD CP program) then why not do it with CHRNs or a VA HBPC physician managed model?


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## Summit (Mar 1, 2013)

Veneficus said:


> Who do these paramedics think they are that they are only around to save lives? What feeble skills do they think they have to do it?



They think they ought to be doing "fun and exciting things" for their $16/hr. That's why street medics last 5 years on average; they get tired of drunks and BLS runs.


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## Wheel (Mar 1, 2013)

Summit said:


> They think they ought to be doing "fun and exciting things" for their $16/hr. That's why street medics last 5 years on average; they get tired of drunks and BLS runs.



Agreed. I wish we could do a better job preparing people for what the job entails, rather than what we want people to think we do.


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## Veneficus (Mar 1, 2013)

Summit said:


> Whenever they aren't busy is like pissin on a fire. Even if we don't talk about which is better, which is easier? Improving availability for home based primary care and home health nursing? Or expanding paramedics to non-EMS roles?
> Again it comes to the insanely broken nature of primary care... why the hell is the system so broken that we need to put a parabandaid on it and want to call it an acceptable solution?



I definately don't call it an acceptable solution, but it is better than nothing.

The other thing we have to keep in mind is community paramedicine whether in Texas, Carolina, or Montana is funded locally. Local economies do not have the resources to fix US heathcare. They have the ability to add a local band-aid.

For the forseeable future it is band-aid or no-aid.



Summit said:


> I guess the real question is, how about that downtime? Are those paramedics out of service when they are half through her med box and a 911 tones out for their area? We know the truth about response times, but when grandma Phyllis strokes out and it take the medics 5 minutes longer to respond because they had to extricate themselves from their "downtime duties" in aunt Florences medicine bin, someone is going to complain, or sue, etc because perception is reality.



The reality is people demand unrealistic response times when they call. If all of your units are busy, then you will have to add more units in order to meet these unrealitic measures ad demands. There will be less downtime for all. 

Eventually your call volume demands will make response times impossible on your budget. (this is seen in every major city every day)

So you can increase the units on the road by 5 or 10% Maybe even 25% in order to meet response times and provide preventative care. 

Alternatively, you could constantly have to be adding to your resources to meet increased demand. 



Summit said:


> Sure. So doees free community nursing.



Yes but communities cannot afford nurses at their salary demands. In areas where EMS is provided by govt agencies, EMS also enjoys increased legal protection against legal action.

From the private EMS standpoint, the operating loss seems to be justified by the maintaining either less resources and/or maintaining profit margins from people who actually pay. The town drunk not on medicare/cade who calls once a day still needs to be responded to per your contract. Those yearly response time summaries don't differentiate who calls or how often.



Summit said:


> If we are talking about altering the national or regional health system models with bandaids like CP, and we are talking about paying for free CPs (like the grant funded ECAD CP program) then why not do it with CHRNs or a VA HBPC physician managed model?



But we are not talking about national or regional change. We are talking about what is locally affordable.

If you do talk regional/national, you are still talking about paying much higher priced providers at a time when cost savings is a higher priority than effectiveness.

Revamping primary care and all the things I talked about in asset retention require no out of pocket expenses, at the national level that can only come from 2 sources. A complete government controlled health system or a government subsidized private health system. The later is what the US has now, how is that working out?

There is simply not the political will to overhaul the current US health system. It will take bodies in the streets before there is.


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## Summit (Mar 1, 2013)

I can't disagree with what you are saying, but I can disagree that we should be resigned to doing what is easy if it is not best.


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## Veneficus (Mar 1, 2013)

Summit said:


> I can't disagree with what you are saying, but I can disagree that we should be resigned to doing what is easy if it is not best.



Then we are in agreement.

I have just given up that the US and its leadership will do what is best.


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## mycrofft (Mar 2, 2013)

Sort of reminds me of the cattle barons who fought losing open range, and the replacement of cattle drives by the railroads building further west. Keep the old and inefficient model because it's what you can excel at and shun the more civilized one because some new pup will come in and do it better. 

There will still be places for rescue and daring-do, just not on our city streets.


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## Bieber (Mar 3, 2013)

As a current CP student, I found the responses to this thread interesting to read. A lot of good ideas, critiques, and observations.

As part of my program, we have to develop an assessment of our own communities and determine the gaps in the local health care system and how a community paramedic program would fill those niches. Working in a large, urban community, I immediately realized that a CP takeover of home health was not a feasible option... There are already tons of home health aid services available, and we'd be competing against every one of them with a much smaller CV to support our cause.

What I DID notice, however, was that in spite of the high number of home health services, we in EMS still encounter what seems to be a high number of patients whose needs are not currently being met. One of the things I will be attempting to determine is whether those home health services are too costly for the uninsured/under-insured or whether the services provided by those agencies are not sufficient to meet the needs of the patients. I suspect the former is more likely but we'll see.

I also oftentimes encounter patients who don't necessarily need EMS transport to an ER, but who would benefit from a followup by some sort of medical provider; or those who refuse transport despite being in a critical condition. I think that these kinds of patients might benefit from aftercare that could be provided by a CP. I also believe that there is a fair sized subset of patients who require immediate or urgent care, but care which could also be provided in a more cost-effective manner than EMS transport to an ER.

Ultimately, the EMS system is broken; it's wildly cost-ineffective, lacking in evidence in a good number of respects, and really our patients deserve more than what they're getting. We won't undo the last forty years of teaching people to call 911 for any and everything under the sun, nor will we be able to improve health care resources outside of our sphere of control, but what we CAN do is increase the bang for the buck in our own industry. Less transport, more treatment, followups, referrals; those are all areas where I personally believe CP programs can lead the way and pave a path toward the widespread adoption of these modalities. Community paramedicine, in my humble opinion, has more to do with improving EMS and ushering in the transformation from emergency medical services to mobile health services than it does with trying to take over the job of anyone else. I don't have any numbers to support it, but it seems to me that the majority of our jobs are more urgent care/primary care based, but paradoxically we have almost no treatment modalities or education in handling them. Community paramedicine, then, isn't about replacing existent primary care providers or home health care providers as much as it is about meeting the needs of our own patients.

Home health nurses are fine, and I don't want to take over their job or the job of any other health care provider, but at the same time I want more options for my patients than to just take them to the ER because we don't have any other care pathways available to us. If a patient is a repeat 911 user because they have a home health problem but no way to afford home health, then the solution is not for us to keep transporting them to the ER over and over again. Whether that's working with a particular home health agency to provide that care for the patient pro bono or us providing that care for them ourselves, as long as we're improving their health and quality of life and doing it in a more cost-effective manner than by transporting them to the ER over and over, I'd call that a win. And that is what I see as the heart of community paramedicine and the future of paramedicine in general: creating cost-effective, evidence-based avenues to care that aren't limited to transport to the ER.

Finally, with regards to those who weren't fans of community paramedicine, I'd encourage us all to remember that EMS is a highly variable industry. In some places paramedics are firefighters first obligated to spend six months in a certificate academy so they can rotate through the meat truck, receive orders from RN's and have a very limited scope and cookbook protocols that they may NOT deviate from under any circumstances; in other places they are associate degree minimums with a scope limited only by their medical director and are expected to be independent, critical thinking clinicians that don't even routinely accept orders from on scene physicians. Because of that, the ideal model is going to be different from location to location depending on the capabilities of the local paramedics as well as of the local health care system. Is a CP program the right thing for every community? Absolutely not. Is it the right thing for some communities? I think so. That's why it's COMMUNITY paramedicine; the needs of the community define the role, scope, and mission of the program.

Like Vene said, paramedics are probably going to be the least economically burdensome model for a program such as this. Not necessarily the right ones in every instance, but neither will nurses or other providers be the right ones in every instance either. It doesn't have to be a nurse, or a paramedic or a mid-level, it just has to work and be cost-effective. But trying to paint EMS with a broad brush (less educated than nurses, less capable than other providers to do the job, etc) is a fallacy given how widely variable the educational level of paramedics is, both between regions and between individual providers.


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