Advanced Skills

mikie

mikie

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I'm just a BLS provider, and per my protocol, I think the most advanced procedure is the Combi-Tube or Glucagon

What is probably the most complex ALS procedure? (Ex: 'surgical' airways or chest tubes)

And if you don't mind answering a second question, do you think there should be somethings that medics (not basics, maybe intermediates) should be able to do or no longer perform?

Thanks!

I'm looking forward to getting some time under my belt then hopefully progressing to higher levels (medic)
 
Well I hate to say it but Michigan is far behind most states, hence I want to move, but anywhoo, as far as here, Paramedics can not nor have ever been able to do chest tubes, but we can do chest decompressions. OUt basics are also not allowed to give any medications, not even Glucagon. I would say our most advanced would be IO, Trach or Crich, or chest decompresion.
 
I have performed in the field: crich's, trach's, central lines, chest decompression, chest tubes, foley's, replaced PEG tubes, placed NG tubes, intracardiac injection & aspiration, I routinely initiated Blood at the scene of trauma of MVC's, even assisted in field amputation at a disaster setting, etc..

Now, with that saying all those are just skills. One has to have the knowledge of when applicable and when it is not. As well, they are not something I performed daily or even yearly. Over the past 30 years, some occurred in very remote settings. Others were performed because I was the highest trained individual, or even the "best" at the time. Some were performed before they discovered it was too dangerous to perform or then later another technique was discovered to be safer and much easier.

One of the reasons I do not like the Scope of Practice is that it might limit EMS. There are areas that need progressive treatment and others that do not. For example some areas might need the ability of chest tubes, where others may not even need the use of IV's in trauma. All dependent upon location, transport times, educational level of the participants, interaction with medical control and medical staff.

So to answer to your question, there is not "one answer". This is what makes setting guidelines so difficult.

For as the question that are some things Paramedics should be able to do or not... Until the education level actually becomes truly standardized with very in-depth accredited collegiate level courses : anatomy/physiology (cadaver lab),(Bio-chem, micro) and increased from a few week course to the very least of 2 years didactic and one year clinical time, past the Basic level (AAS) then each skill needs to be evaluated as "need to know and perform" basis. Yes, each may be taught but may not have protocol to utilize. Again, all dependent upon the care that would be required to deliver to the patient.

R/r 911
 
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Just curious Rid. When would you ever need to insert a foley catheter in the field?
 
I personally believe that foley catherization is one of the most under used advanced skills. One of the only true documentation of shock management is urine output (<30 ml/hr) as well a strict I & O for burn patients. CHF patients that are > 30 miles when they have been administered IV diuretics, head injury patients that have been given osmodiuretics, etc.. In realistic terms it is the one of the best vital signs available. Kidney function is an important key of knowing your patients perfusion level (especially if placed on vasopressors).

I was the first Paramedic in my state to by-pass a local ER to go the nearest Trauma Center (55 miles away) on a severe trauma patient. A bi-lat amputation, we had intubated, established bi-lat IV's, and plasmanate, NG tube and yes foley. Upon arrival, the physicians questioned why I did not stop at local ER's while enroute. Of course being a teaching facility, they even questioned my and another Paramedic intubation (even though the patient was sat 100% and no gastric distention and bi-lat lung sounds/EtCo2 was not invented yet). This call brought a hornets nest of acquisitions against me in front of the medical examiner (license) board. The reason being at the time, I should had stopped at local ER's (P.A. staffed or awaited an additional 40 minutes for blood and no surgical intervention) To make a long story short, my documentation of strict I & O as well as other documentation, saved my career and was a pivotal change in EMS care.

That incident made me determined to change things, enough so that I pursued further education and worked in trauma studies for about 3 years. While doing, worked full time in constructing my states divert and by-pass protocols and assisted in writing the State Trauma plan including Trauma Center guidelines. Paramedics would never be hassled again for taking the patient to most appropriate facility instead of the nearest.

I have found one of the reasons most medics do not want to place foleys is simple. It involves the genitalia. Many believe it is beneath them to do so. They much rather have the patient lay in piss, wet clothes, and simply do not care about the patients comfort. (One should attempt to have to urinate while on a LSB going over bumps/railroad tracks, etc).

Not all services or EMS should even consider this procedure, however; in rural, remote or long distance transfer a definite yes. This procedure is simple, fast and not complicated.

I believe as we mature in true patient care, we will see a more shift in actually delivering care. Again, knowing output is essential in assessment, as well as for patients comfort. Just like many other procedures that was thought as taboo, now are routine.

R/r 911
 
^ I don't think I could've asked for a better answer! Thanks
 
mikie333 said:
I'm just a BLS provider, and per my protocol, I think the most advanced procedure is the Combi-Tube or Glucagon
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EMT-Bs here are not aloud to do a combi-tube or give Glucagon. EMT-Bs give dextrose orally. Anything that involves a insertion of a needle is out including checking B.S. We only use OPAs and NPAs. Of course medics are dispatched on every call and we are 10 minutes from a trauma II center.
 
Ridryder911 said:
I was the first Paramedic in my state to by-pass a local ER to go the nearest Trauma Center (55 miles away) on a severe trauma patient.
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Ridryder911 said:
That incident made me determined to change things, enough so that I pursued further education and worked in trauma studies for about 3 years. While doing, worked full time in constructing my states divert and by-pass protocols and assisted in writing the State Trauma plan including Trauma Center guidelines. Paramedics would never be hassled again for taking the patient to most appropriate facility instead of the nearest.
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Ridryder911 said:
Not all services or EMS should even consider this procedure, however; in rural, remote or long distance transfer a definite yes. This procedure is simple, fast and not complicated.
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Rid, it's been 30 years since you (and I) got into this field. A lot has happened. Many procedures that we did in the 70s and 80s have given way to improved trauma systems and better alternatives for equipment. We also found out that maybe intracardiac injections and central lines (subclavians were big then) were not always the answer. And yes, femoral lines are still popular after other alternatives are deemed not feasible.

There were other issues with transporting to hospitals in the 80s besides traumas issues: HMOs. We were put on some serious round about excursions because of them. If ambulance people think they do a lot of transfers now, the 80s were torture.

EMS was young then and we could take a few chances with the blessing of our medical director. However, today, it is nice to have someone backing you before you do anything too radical.

Rid, you now have an impressive list of credentials behind your name and now have accomplished many skills that are considered fundamental to you. Many Paramedics are still trained with less then 6 months of education and many that are accepted by the Medic Mills lack both maturity and a solid clinical experience before being placed on an ambulance.

The latest issue to shake up the hospitals is Medicare refusing to pay for hospital acquired infections. That is also one reason our hospitals pushed for their own transport teams and equipment for interfacility. They needed to control the quality of training, education and cleaning issues for infection control. We are currently culturing every lines and tube again. We did get a little lax on field sticks for awhile and went to 48 hours for change out. Now, they want to ED nurses to get rid of the field IV before the patient moves anywhere. Of course, if the site was contaminated with the first stick, the patient is already at risk. And yes, everybody is aware of all the studies out there which vary from patient population to county and system. But, it just takes a few bad experiences to get people changing policies and/or finding better alternatives.

I, too, moved on to and advanced scope of practice with flight and specialty transport, but I still respect every procedure granted to me. Education and training should be continous and not just in paramedic school or a refresher every two years. If you want the privilege, it takes effort.
 
Vent, I respectfully agree. What I hoped to describe is that many of the so called "big time procedures" were nothing more than routine procedures after one had mastered it. As well, as you describe many are no longer needed or as I described was found to be dangerous or make no difference in outcome. For example, with the introduction of adult I/O the use of performing central lines should be heavily researched upon why they should be performed both in the field and even in the ED setting. (this would be shocking to 2'nd year ER residents).

I agree, I do chuckle when I hear those complain of transfers. I remember viewing our "schedule board" of having at least 16 scheduled clinic transfer per truck on top of the 911 emergency calls. Yes, we kept extra stretchers at the physician offices for just that reason. I agree, EMS administration took advantage of Medicare payments as well. I seen fraud in EMS when I saw an EMS take a patient to the dentist or even to the pharmacy/grocery store.

We have Paramedic mills here as well. This has been very controversial for those that attended well established programs and those that attended shake & bake programs. Sorry, even if one is relatively intelligent the demand upon on what is to be learned or required, versus as just enough to get by. One can definitely tell the differences upon entry to the work place, maybe not immediately but later as one becomes more acquainted with their profession and treatment regime.

What I hope not to see is a "mold" type of EMS Scope of Practice. Every system has some general similarities, and yet they have unique individual areas where more advanced or aggressive treatment should be considered. If we allow the status quo to continue and not demand more, our profession is headed for dire trouble and extinction. Someone else will step in and take over.. (hint: look at Doc (PA/NP in the box) and how the HMO and insurance corporations love them. Again, financial ends will determine our direction, it is our choice to allow it or change our thinking..

Sorry for the hijack..

R/r 911
 
Ok, this question is aimed to Rid and Vent, and is a serious one.

I have recently been speaking with the director of the local community college; who is considering; given a recent expansion grant for a new trauma nursing lab, A & P labs, micro labs, and S.M.A.R.T. classrooms, implementing a Paramedic program into the college's majors. The college currently offers EMT-IV(I went through their program); as well as RN, A.A.S. What, if anything; would be the best approach to convince her to implement a well-rounded 2 year Paramedic degree as opposed to a one year certificate program? Are their any studies I should cite?

I posted a thread not to long ago with regard to shaping a paramedic program; around a basic nursing curricula; substituting Nursing I-IV with Paramedic I-IV; the remaining curricula being:

English Composition I
English Composition II

Fundamentals of Public Speaking or Communicating in the Professions
Music, Art, or Theatre Appreciation(TN board of regents Gen Ed Requirement)

Math 1530: Elementary Probability & Statistics
Net 1070: Dosage Calculation

Biol 1010: General Biology I

Chem 1020: Chemistry for the Life Sciences(Clinical Chem)
Biol 2230: Health Science Microbiology(Applied Micro)
Psy 2310: General Psychology I

Biol 2010: Anatomy & Physiology I
Biol 2020: Anatomy & Physiology II

HEC 1010: Fundamentals of Nutrition

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This curriculum, including Paramedic I, II, III, & IV teaching the core competencies of paramedicine, in my opinion, would foster a better understanding of the human system as well as a more informed patient care.

Also, with the growing popularity of Paramedic to RN transition programs, the aforementioned curricula(being the current nursing gen ed curriculum) would ease the transition significantly; allowing the year transition to consist of only Nursing I, II, III, IV and some bridge curricula, and alleviating concerns of hospitals seeking to hire RN's from Pmed transition programs.

In addition, I feel that with the new resources(the new trauma lab, etc); RN students and paramedic students could get together in the labs performing their duties; fostering a working relationship between the two professions whilst providing a great educational opportunity.

I guess what I am asking is; what data can I present to Dr. Edmonds(Director) to convince her that a degree program would be better
than a certificate program?

"Dreams of a world where Paramedics and RN's can hold hands in places other than helicopters", lol.
 
Personally I believe that any and all paramedic programs should be at least a 2 year degree with the remaining 2 semesters being nothing but ride time. The classroom cannot teach everything a students needs to know, but an extra year in the street would greatly help.
 
Below are examples of Florida's colleges that offer a 2 year degree. Almost all of Florida's colleges offer a 2 year degree, and many have since the 1970s, they have the option of just a certificate.

Colleges receive funding based on the number of students their programs can attract and graduate. If the two year degree is not mandatory and does not offer a certificate program, students may look for another school.

If your school offered only the 2 year program while your state still mandated only a certificate, that could give rise to a few "Medic Mills".

The certificate programs keep a high volume of students applying with a good completion rate.

All the science classes are shared with other allied health professions and nursing. There is no distinction as to what program you are taking while in these classes.

In Florida, although we started as the leader in degree programs, we became better known for our Medic Mills. The colleges' certificate programs also had to compete with them to attract students. The Medic Mills had flashy ads and easy financing. They were attracting student even though their cost started at $10k versus the $2500 at a community college.

I've also listed the certificate part of the degree so you can see how schools are using more than the usual college catalog format to attract students into their programs to keep the students applying. Since the word "Academy" is used LAW and FIRE, it is now common in EMS an advertising pull used competitively to attract students.


http://www.spcollege.edu/program/EMS-AS
http://www.spcollege.edu/program/PMED-CT

http://www.mdc.edu/medical/academic_programs/index.htm
http://www.mdc.edu/medical/academic_programs/paramedic/paramedic.htm

http://www.pbcc.edu/x1264.xml

Non-college programs that just meet the 1100 hours required. Catchy ads and they also have impressive TV commercials with lots of action and drama. "That could be you in just a few short months".
http://www.fmti.edu/index.html
http://www.americanmedicalacademy.com/index.html
 
In response to the original post, surgical crics, chest tubes, RSI, etc are not that complex to perform. The complexity comes from actually making the decision to do it. Once you start, you're committed. You'd better be right in doing it in the first place.

Answer to 2nd question: Yes, the above procedures should ONLY be performed by medics who:

1) have proper training
2) have proper QA/QI
3) strong Med Control backing
4) proper continuing education/training
5) it better be strict

If you don't have all 5, then the answer is NO! Don't do it.
 
Most complex procedure or skill a paramedic performs? Our assessment. That is what seperates a paramedic from a basic, and a good medic from a bad one. Without that, everything else we do is a moot point.
 
The program I went through required the following classes:

Paramedic 1, 2, 3
A&P 1, 2, 3
Biology
Chemistry (both low level courses)
Health and Wellness (something like He275)
Fundamanetils of Public Speaking
Math 170
Psychology (lower level)
Medical Terminology
Intro to EMS
EMS-Rescue
Communication & Documentation (chart writing)
Crisis Intervention & Management
2 electives
Writing 121
Computers (a basic course on the use/programming of computers)
I think that's it. May have left something out though. Technically some of the classes (computers, health, electives) can be done at the same time as the medic class, but I don't know of anyone who did that. The rest are required to be completed before you enroll in Paramedic 1. I gotta say I like the program; the actuall paramedic class can focus almost soley on paramedicine as most of the rest has been covered. The only addition I'd like to see is a dedicated pharmacology course.
 
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In response to the original question, this is a partial list of ALS skills. Every state has its own variation of scope of practice and what is considered advanced scope.

Paramedic:
Chest Decompression – Needle
Chest Tube Monitoring
Cricothyroidotomy – Needle
Cricothyroidotomy – Surgical
Gastric Decompression – NG and OG Tube Insertion
Cardiac Monitoring – Multi Lead (12 – interpretive)
Peripheral – Including External Jugular – Initiation
Urinary Catheterization
Chest Escharotomies

Advanced skills:
Chest Tube Insertion
Intubation – Medication Assisted (paralytics) (RSI)
Intubation – Retrograde
Arterial Blood Pressure Indwelling Catheter – Maintenance
Invasive Intracardiac Catheters – Maintenance
Central Venous Catheter Insertion
Central Venous Catheter Maintenance/Patency
Central Venous Catheter Maintenance/Interpretation
Percutaneous Pericardiocentesis
Ventricular Assist Devices
Blood/Blood By-Products Initiation (prehospital initiation)
Transvenous Pacing – Maintenance
Maintenance of Intracranial Monitoring Lines
Aortic Balloon Pump Monitoring

A short "critical care" certification class is only an overview and does not replace actual training with a medical director's attention.

For the Advanced skills, to quote MSDeltaFlt
1) have proper training
2) have proper QA/QI
3) strong Med Control backing
4) proper continuing education/training
5) it better be strict

If you don't have all 5, then the answer is NO! Don't do it.
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