# Critical Care Paramedic: Should this exist?



## sneauxpod (Feb 10, 2014)

Now depending on the state that you practice in, you may need to take special classes to use vents, pumps and certain drugs. Currently, I practice in Louisiana which is the case. I am a transplant down here though. In Michigan where I initially got my license, I was trained to use pumps and vents and as far as I am aware, I could have been trained on CCT drugs as well, but due to the area I worked in, it wasnt exacAbtly necessary due to the close proximity to the hospitals. So my question to you is, should a CCT course be integrated into a normal paramedic's schooling or should it remain a separate, elevated level?

Personally, I feel as though it should be integrated for several reasons.

I believe that it would advance the field towards a more educated nurse-like education level
Potential for increased pay across the board were it nationally accepted
Potential for better patient care overall
Ability for services (mostly private) to handle resources more efficiently
It would also save us a ton of money in initial class fees for the CCT class itself, (since this would more than likely bump up the amount of CEs per year, which, spread out would be a lot less of a hit for most).

I do understand that there are also downsides to this, but I believe in the long run it would be better for the field overall. 

What do you think? Why do you think that?


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## Handsome Robb (Feb 10, 2014)

I've always said EMT should be ILS and an AS, then Paramedic is a BS and CCP is a MS/post graduate certificate.

A true critical care environment involves complex patients and medications, we already talk about skill degradation at the ALS level, we can't be proficient with the stuff we already have why force people, many of which who have no interest in critical care and very little interest in Paramedicine anyways, to take a class. I don't see the gain for having every medic be a CCP.

We need to get good at what we do already and sort out all the problems in our baseline education before we start trying to add more "toys".


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## triemal04 (Feb 10, 2014)

No.  Not a chance.  No way in hell.  Terrible idea.  Completely ridiculous.  Waste of time and resources.  Detriment to the profession.  Embarrassment to the profession.  And anything else in that similar train of thought.

EMS is already woefully unprepared for the things that we are currently expected to do, and that we could do if we used our routine equipment and abilities to the highest level.  Introducing more complex equipment, assessment capabilities, and treatment pathways before we can figure out what to do with what we have is beyond stupid.  

First fix what we have, then look at the need to add additional capabilities.


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## sneauxpod (Feb 10, 2014)

Robb said:


> I've always said EMT should be ILS and an AS, then Paramedic is a BS and CCP is a MS/post graduate certificate.
> 
> A true critical care environment involves complex patients and medications, we already talk about skill degradation at the ALS level, we can't be proficient with the stuff we already have why force people, many of which who have no interest in critical care and very little interest in Paramedicine anyways, to take a class. I don't see the gain for having every medic be a CCP.
> 
> We need to get good at what we do already and sort out all the problems in our baseline education before we start trying to add more "toys".



I think that due to the added degree of difficulty with the CCT, those who don't apply themselves like it were a full on college program and become proficient in at least the schooling for this field would be weeded out prior to even testing to getting a license. Though I do agree with your standpoint on how the schooling for each level should be.


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## Handsome Robb (Feb 10, 2014)

sneauxpod said:


> I think that due to the added degree of difficulty with the CCT, those who don't apply themselves like it were a full on college program and become proficient in at least the schooling for this field would be weeded out prior to even testing to getting a license. Though I do agree with your standpoint on how the schooling for each level should be.




With that setup you could add community medicine as a MS as well and start having specialties and advanced practice paramedics however that's a topic for another thread.

Sure they'd be weeded out and probably would never sit for the test so that's a great reason not to include it...why not use that time for something that will add to the current curriculum and fix the insufficiencies that are already present than try to add another certification on top. You're doing both the students that don't intend to take the CCP test and those who do intend to a disservice. One by using time that could be better used elsewhere and two because you're not going to be able to properly teach the subject matter to those that want to learn it.


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## sneauxpod (Feb 10, 2014)

Robb said:


> With that setup you could add community medicine as a MS as well and start having specialties and advanced practice paramedics however that's a topic for another thread.



Agreed.




Robb said:


> Sure they'd be weeded out and probably would never sit for the test so that's a great reason not to include it...why not use that time for something that will add to the current curriculum and fix the insufficiencies that are already present than try to add another certification on top. You're doing both the students that don't intend to take the CCP test and those who do intend to a disservice. One by using time that could be better used elsewhere and two because you're not going to be able to properly teach the subject matter to those that want to learn it.



I partially agree. Granted it wouldn't fix all of the insufficiencies that are out there, it would help advance the field by attempting to have only the upper tier make it in, which is what nursing schools make an attempt to do. I dont know many paramedics who say they don't have any compulsion to learn CCP skills and such, what I always hear is its a financial problem so I cant personally speak for that. Also, in the current "standard" format of schooling it would not be very effective, but if it were to be extended say another six months or a year I think it would be more than acceptable.


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## mycrofft (Feb 10, 2014)

Since EMT's emerged in the Seventies, states and some employers have clamored for more varieties of emergency techs to replace professionals in non-emergency roles to save money and broaden their hiring base. In turn, people want to work in the medical field with a tech school education.

You figure out the answer.


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## Carlos Danger (Feb 10, 2014)

sneauxpod said:


> So my question to you is, should a CCT course be integrated into a normal paramedic's schooling or should it remain a separate, elevated level?



The problem with this is that you aren't just talking about adding a few hours to the current curriculum; in actuality you'd probably have to double both the classroom and clinical components of paramedic school. If you did it right, anyway.

And this stuff just isn't what most paramedics do. You'd be spending all this time and money making paramedics learn things that they just won't use. 

If you want to add a little more training in vents and hemodynamic meds, that is probably reasonable. But I think it makes more sense to keep CCT as a specialty that a paramedic can learn after gaining some basic ALS experience.


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## Ridryder911 (Feb 10, 2014)

The national curriculum does not include topics like you pointed out. Hence the wording comes from payment structures of what is defined as a Critical Care Paramedic.. " _beyond normal Paramedic training or needs of respiratory care or requires a Registered Nurse"_...Sure, many education facilities has those topics within their Paramedic curriculum but; when one starts really focusing on how much pharmacology, hemodynamics and hands on critical care; how much is really retained or taught? 

It is time for those in EMS to get real. *Emergencies do not pay*. Subsidy to EMS continues to increase and the public is getting tired of paying additional revenue(s) to fund public services. Yes there will always be a need for first responder(s) but there is life in EMS after basic Paramedic. Should we stop growing?
Yes, I agree we definitely need to fix the problems in EMS, but in the meantime medicine continues to grow and change.. either we can a part of it or be left behind. I predict the term EMS will be a thing of the past within a decade. Out of hospital care, or Mobile healthcare. 

Either we can part of the solution or be narrowed out. With newer rquirements and increasing IFT and critical care transports increasing, do you want a RN/CCT to do the job or a Paramedic? Personally, I would think those in EMS would want to be part of the solution and not want others to start mandating and proposing on how it should be performed. 

Requiring a post graduate level would be great but ... and then let's be realistic; one could be a PA, NP or equivilant with the same level of education. What payment structures could be attached to subisidize this level? Then why not employ those with those accepted credentials? Is it a possibility? I don't know but would hope so, I do think the possibilities are endless. It would be nice to see Paramedics have a potential expanded career than just in the EMS field. 

I am on a comittee attempting to start a BS for Community Paramedicine. I know there is discussions on a national level of changes of the role of Paramedic. I believe alike in nursing, you will be able to branch off the main focus and expand your knowledge and career. 

R/r 911


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## MrJones (Feb 10, 2014)

How 'bout we start with the basics. Like, I long for a world where the "XXLS" cards are superfluous because it's expected and accepted that Paramedic training includes adequate and appropriate preparation for dealing with cardiac/trauma/pediatric/etc (i.e. to a level equal to or exceeding that allegedly attained by passing those "XXLS" courses). 

Get me there, and _then_ let's talk about incorporating CCT skills


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## EpiEMS (Feb 10, 2014)

MrJones said:


> How 'bout we start with the basics. Like, I long for a world where the "XXLS" cards are superfluous because it's expected and accepted that Paramedic training includes adequate and appropriate preparation for dealing with cardiac/trauma/pediatric/etc (i.e. to a level equal to or exceeding that allegedly attained by passing those "XXLS" courses).
> 
> Get me there, and _then_ let's talk about incorporating CCT skills



Much as this is a great idea, there is an issue: just because the training includes the material doesn't mean that regular protocol/state of the science updates and refreshers aren't required. For example, even physicians with residency training are (often) required to maintain certification in a number of XXLS courses. I would think you'd be hard pressed to find an EM physician who isn't required to maintain current ACLS and ATLS certification. The best aspect of these courses is that refreshing oneself, admittedly, not necessarily in a rigorous manner, is required.


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## VFlutter (Feb 10, 2014)

Robb said:


> A true critical care environment involves complex patients and medications, we already talk about skill degradation at the ALS level, we can't be proficient with the stuff we already have why force people, many of which who have no interest in critical care and very little interest in Paramedicine anyways, to take a class. I don't see the gain for having every medic be a CCP.




Agreed. I think "Critical Care Paramedics" have a place as part of a CCT team, as an adjunct to a CCRN, but likely will never be suited as sole providers. It is nearly impossible to maintain competence. Unless these paramedics were part of a hospital system and rotated through the ICUs periodically. Even in the ICU taking care of Critical Care patients all day every day it is hard to maintain adequate exposure and competence on some of the equipment and conditions. Let alone only seeing a (IABP/CVVHD/Bolt/etc) patient only once a week for only a few hours, if that.


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## VA Transport EMT (Feb 10, 2014)

I think we need a ccemt or an emt with Knowledge about cct pts.


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## Handsome Robb (Feb 10, 2014)

I know in going to catch flack for this but no, we don't need an EMT. I'll take a medic with CCT experience though. I promise they're going to say what's already been said.


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## Tigger (Feb 10, 2014)

VA Transport EMT said:


> I think we need a ccemt or an emt with Knowledge about cct pts.



What for, exactly?


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## Akulahawk (Feb 11, 2014)

Chase said:


> Agreed. I think "Critical Care Paramedics" have a place as part of a CCT team, as an adjunct to a CCRN, but likely will never be suited as sole providers. It is nearly impossible to maintain competence. Unless these paramedics were part of a hospital system and rotated through the ICUs periodically. Even in the ICU taking care of Critical Care patients all day every day it is hard to maintain adequate exposure and competence on some of the equipment and conditions. Let alone only seeing a (IABP/CVVHD/Bolt/etc) patient only once a week for only a few hours, if that.


Given the right education and experience, I think it's completely possible for a Critical Care Paramedic to be a sole provider in much the same manner that an ICU RN is a sole provider. Ideally, these CCTP's would be rotated through the ICUs but they also see critical patients every day, provided we keep the number of providers ideally low so that there's little skill/knowledge dilution. 

Here's the problem: educating the Paramedic to that level would necessarily take a long time. Remember, I'm _not_ saying that they need to be taught _nursing_ but rather that which is needed to provide medical care during transport between facilities. They'd be a specialist in that role. Given the low number of Transport Providers, they'd see several critical patients every day because that's all they do. 

This would not be a trivial endeavor. Not by quite a bit!


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## MrJones (Feb 11, 2014)

EpiEMS said:


> Much as this is a great idea, there is an issue: just because the training includes the material doesn't mean that regular protocol/state of the science updates and refreshers aren't required. For example, even physicians with residency training are (often) required to maintain certification in a number of XXLS courses. I would think you'd be hard pressed to find an EM physician who isn't required to maintain current ACLS and ATLS certification. The best aspect of these courses is that refreshing oneself, admittedly, not necessarily in a rigorous manner, is required.



That could be said about pretty much every aspect of our profession; that's why we're required to receive continuing education on a regular basis. No need to tie that continuing education to an "XXLS" card when it can be tied just as easily to our license.


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## VA Transport EMT (Feb 11, 2014)

Some more a&p, dialysis problems, assisting with vent settings, know what types of caths, just stuff that would help us out and not require loads of training when we get a cct job.


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## Merck (Feb 11, 2014)

Chase said:


> Agreed. I think "Critical Care Paramedics" have a place as part of a CCT team, as an adjunct to a CCRN, but likely will never be suited as sole providers. It is nearly impossible to maintain competence.



Here we run a CCP/CCP model for all critical care transfers withing the province.  Our CCP training above ACP (Paramedic) is 2 years.  During our program we complete the post-RN courses in crit. care nursing from a well-respected post-secondary institution here.  The rest of our program is taught primarily by intensivists.  We are actually pretty proud of our program and find that the addition of an RN would do little to help and would likely hinder our service.  I know it's how most of the rest of the continent works but for us the idea is foreign.  

As to the OPs point - I don't think adding a few bits and pieces to a paramedic course would add value.  Be a paramedic.  Then if you want more, be a CCP.  Learning skills and rarely using them is a good way to hurt people in the long run.


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## Carlos Danger (Feb 11, 2014)

Akulahawk said:


> Given the right education and experience, I think it's completely possible for a Critical Care Paramedic to be a sole provider in much the same manner that an ICU RN is a sole provider. Ideally, these CCTP's would be rotated through the ICUs but they also see critical patients every day, provided we keep the number of providers ideally low so that there's little skill/knowledge dilution.
> 
> Here's the problem: educating the Paramedic to that level would necessarily take a long time. Remember, I'm _not_ saying that they need to be taught _nursing_ but rather that which is needed to provide medical care during transport between facilities. They'd be a specialist in that role. Given the low number of Transport Providers, they'd see several critical patients every day because that's all they do.
> 
> This would not be a trivial endeavor. Not by quite a bit!



Yeah, there is no question that paramedics _can_ learn critical care well enough to work alone (see Merck's post above). 

The question is, why go to the time and expense to implement that extensive training when there are other professionals (RN's and RRT's) who already have the knowledge and experience to do CCT?

I don't care what letters you have behind your name, if you have the experience to do the job, knock yourself out. The problem is, it takes a lot of experience to do CCT. If you have a way to gain that experience, great. But I just don't see the rationale for developing a lengthy, expensive training program for paramedics when there are others who can already do the job without the lengthy, expensive training program.


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## unleashedfury (Feb 11, 2014)

Halothane said:


> Yeah, there is no question that paramedics _can_ learn critical care well enough to work alone (see Merck's post above).
> 
> The question is, why go to the time and expense to implement that extensive training when there are other professionals (RN's and RRT's) who already have the knowledge and experience to do CCT?
> 
> I don't care what letters you have behind your name, if you have the experience to do the job, knock yourself out. The problem is, it takes a lot of experience to do CCT. If you have a way to gain that experience, great. But I just don't see the rationale for developing a lengthy, expensive training program for paramedics when there are others who can already do the job without the lengthy, expensive training program.



True, that.


I think the two biggest yielding factors is 1. If you want to lengthen the paramedic program, and limit the "I'm just here for the card" its a matter of AAS minimum and we need to be focusing much stronger on the skills we already have rather than a minimal education of those skills. 

As far as CCP that's a specialty course if you have the capabilities to maintain your level of skill and knowledge in such a environment sure go ahead. But how many paramedics work for fire depts. Municpal based EMS systems and 911 only systems that will never need or use this education? Allow the ones who want to be CCP's become one, and ones that will use the skills on a IFT truck or in a hospital obtain this certification.


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## mycrofft (Feb 14, 2014)

Hip-shots:
1. Rid, I agree mostly. There are strong societal pulls to continue the current model. (Remember how in the Eighties "HMO"'s would be villages of proactive health, and all they basically are now is medical conglomerates with advanced case management office facilities?). Hospitals will fight to remain the center of care, and employers will strive to keep jobs at tech levels and techs "illiterate, barefoot and pregnant" or whatever the educational equivalent is. And risk management will want to bring care under the physical plant of the hospital since they have no control over "The Outside". (e.g., places which customarily d/c field IV's and restart their own "just because"…just because if a field start gets infected they get hit for something they didn't start).

2. To all: the EMT-Ambulance and EMT-Paramedic model I think is still viable if the mission is to quickly spread trained and systematic EMS through the land, including rural and maybe frontier/wilderness areas. Tweaking it up requires new extension (paradigms?) of the community care and support infrastructure ($$$$$$$$$$$$$$$ and recruiting) which we have failed so far to meet.*

3. I agree with knowing about various classes of patients so we can meet their needs generically, but remember anytime you get more skills you have to not only take your biennial CEU's, but _*actually use them, under supervision, successfully. *_


*I remember when hospitals had their own helicopters, mobile ICU's, (and in one case almost got a converted Army riverine BOAT) as intake modes for high acuity patients….then quit it because those are money losing patients.ALso they die and skew your stats down.


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## MonkeyArrow (Feb 14, 2014)

I agree with all of the posters before me as to the ineffectiveness of this model for the current EMS system as some people are just not willing to work to train to the level needed to actually be called a CCT unit and others, as much as they read their textbooks and practice on the manikins, will not get the field time to be properly exposed to these scenarios to keep their skills on real pts fresh. Similar to the whole rural paramedic not getting high intubation success rates and some suggesting removing it from the scope, but I digress…

What I think is of interest in the CCT model is whether CCT should become a part of the 911 response matrix. For example, any time a peds call comes in, roll a CCT unit Code 3 to the scene or anytime a code comes in or whatever, make them the new ALS providers. House them in the fire stations or in the parking lots or whatever and allow them to be available to respond to emergency calls as well as the usual IFTs. If you don't agree with the above model, do you see our system headed down that path? With the widespread scope reductions or already dismal, insulting scopes (EMT-Bs in some states) etc., do you see the current system headed that way where eventually, the paramedics aren't getting proficient in the ALS skills and they get replaced with CCT rigs.


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## 18G (Mar 11, 2014)

There is definitely a need for critical care paramedics. I don't think there is much dispute in that especially for inter-facility transport. Where I work, the Paramedic is the primary critical care provider. Rarely, do we require an RN. It would be nice if there was a standard curriculum for critical care paramedics. The UMBC course is very elementary and offers nothing more than an introduction to inter-facility transport for the 911 Paramedic. Anyone who has done IFT will already know the majority of the info in the UMBC course.


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## MGretz70 (Mar 12, 2014)

I think there is a need for Critical Care Paramedics. I don't think it should be added to the curriculum of Paramedic class though as we have enough to learn, remember and practice already with adding all of critical care transport stuff thrown in on top of that. It's my personal belief that you should have a minimum of 5 years of being on a busy service before attempting Critical Care Curriculium and start getting involved .


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