Community Paramedics revisited

[ExpatMedic0]

You make some very valid points, and although I do not agree with all of them, its not the first time I have seen them. You could be right about every single one of your points, its to early for me to say and I think they are all valid concerns.
This whole concept has just seen a huge revival lately for whatever reason. Personally I think its because of the new health care act and those other articles I posted related to it.
The ultimate education goal appears to be a masters for community Paramedicine, per the presentation I posted above. I am on my last year of undergrad studies, shopping around for graduate school, including MPH programs.
I love EMS and I would love to see it grow as a profession. I personally intend on following this concept more. I will post new information on this thread when it becomes available so we can discuss and analyze this concept further and I would welcome you to do the same, even if its information which is not so optimistic ;-) so long as its pertinent.

 

[Arovetli]

I probably came across a bit more negatively than I intended. I hope EMS grows as a profession and I intend to work towards bettering it, but I find it incredibly irksome that the notion of expanding into rural primary care is the future of the field. Paramedics as a whole struggle with the things they are already tasked to do: intubations, STEMI recognition, triage decisions, etc. Let's put what little money and energy we have into making the EMS system workable, efficient and competent. I support growing the skills and knowledge base of a paramedic, treat and release, alternate destinations, all that stuff.

The concept is not really a revival, decades ago midlevels were created with hopes that they would go to rural boondocks county and provide primary care. What actually happened is they followed the money, like everyone else does, and went where they were paid best, treated best, and could live best. Paramedics are an economic anathema: they will perform advanced skills for poor compensation...and many do it for free. Don't think for a second there is a businessman willing to profit off of the altruism of another, and that is what your going to get with a rural medic. Going to North Dakota and doing teeth cleanings and basic abx rx's and anti-tobacco education for $25/hr isn't going to change life for the other 99% of paramedics getting their butts kicked on the 911 truck.

If there was any money to be made out here I promise you the powerful nurse lobby or any number of other professions would snatch it up and legislatively lock out medics. EMTs and paramedics have free reign in the prehospital environment because no other profession wants it.

Lets grow EMS in the field it was planted, and work to get it recognized and reimbursed and legislatively protected accordingly. The people supposed to be doing this are failed leadership who invent pyramid scheme training programs so you can have a new provider card in your wallet and they can have your money in their wallet. But that is my cynicism talking again...

 

[Arovetli]

Oh I would note that all my remarks are addressed to the USA, in other countries this is so much more feasible.

Big money is coming into American EMS by way of Falck, Warburg Pincus, and CDR. These corporate jokesters are not buying up ambulance services because they want supermedics, but because they know they can work you like a beast, pay you very little, and scrape a nice profit margin out of transporting government insured patients.

Just wait 'til the Bentham-esque utilitarianism big money corporations love comes to bear on the EMS system.

Last I checked, Detroit and DC and NO cant afford paramedics and their EMS system is crumbling to dust. Last service I worked at in a major metropolitan area had no trucks with less than 300k miles on 'em. Lets fix that before we go off trying to reinvent ourselves, because that is an attempt to escape the responsibility we have, which is acute and emergent care and transportation.

 

[Carlos Danger]

I probably came across a bit more negatively than I intended. I hope EMS grows as a profession and I intend to work towards bettering it, but I find it incredibly irksome that the notion of expanding into rural primary care is the future of the field. Paramedics as a whole struggle with the things they are already tasked to do: intubations, STEMI recognition, triage decisions, etc. Let's put what little money and energy we have into making the EMS system workable, efficient and competent. I support growing the skills and knowledge base of a paramedic, treat and release, alternate destinations, all that stuff.

The concept is not really a revival, decades ago midlevels were created with hopes that they would go to rural boondocks county and provide primary care. What actually happened is they followed the money, like everyone else does, and went where they were paid best, treated best, and could live best. Paramedics are an economic anathema: they will perform advanced skills for poor compensation...and many do it for free. Don't think for a second there is a businessman willing to profit off of the altruism of another, and that is what your going to get with a rural medic. Going to North Dakota and doing teeth cleanings and basic abx rx's and anti-tobacco education for $25/hr isn't going to change life for the other 99% of paramedics getting their butts kicked on the 911 truck.

If there was any money to be made out here I promise you the powerful nurse lobby or any number of other professions would snatch it up and legislatively lock out medics. EMTs and paramedics have free reign in the prehospital environment because no other profession wants it.

Lets grow EMS in the field it was planted, and work to get it recognized and reimbursed and legislatively protected accordingly. The people supposed to be doing this are failed leadership who invent pyramid scheme training programs so you can have a new provider card in your wallet and they can have your money in their wallet. But that is my cynicism talking again...

I made a very similar case in another thread on this same topic. I think the demand for community health paramedic services as a new, reimbursable paradigm is low and the barriers large, and more importantly, I think there is a heck of a lot we can/should do without going down that path.

If the government decides to increase funding for community health initiatives, it makes more sense to simply expand the existing infrastructure than it does to invent a whole new provider. We already have NP's, PA's, and CHRN's. The existing entities all have more political pull than EMS, and will quickly snatch up any funding made available. And as a taxpayer who would rather see his tax dollars go towards the actual delivery of care rather than towards funding redundant educational programs, I wouldn't necessarily disagree with that.

Now, that said.....

One of the big problems with paramedic education is that it is still focused solely on life-threatening emergencies even though those requests make up a very small percentage of what paramedics actually do. For that reason, it makes good sense to me that paramedic education and mindset would shift from its emergency focus to one where the importance of basic non-emergency care is increased.

I would re-design paramedic education to take a full two years (at least), and the curriculum would spend at least as much time on non-emergency as on emergency care. Paramedics would still learn to do EKG's and ACLS and PALS and airway management, but rather than pretending that's all there is to prehospital care and then having to schlep everyone to the ED whether or not they need it, medics would also be in a much better position to implement protocols that allowed for "treat and release" and for referral to clinics. Asthma attacks, diabetic wake-ups, minor burns, minor lacerations, and drunks would no longer have to receive the same disposition as a STEMI or a stroke.

And I wouldn't call this a "community health paramedic"; I would just call it a paramedic who is better trained to do what we are already called to do most of the time anyway.

I would much rather see the EMS community get behind the idea of increasing and improving basic educational standards and making them reflect the realities of what paramedics actually do. To me that makes a lot more sense and is a lot more realistic than all the push towards the community health or critical care stuff.

 

[Summit]

I think Halothane hit the nail pretty square on.

 

[Wheel]

I made a very similar case in another thread on this same topic. I think the demand for community health paramedic services as a new, reimbursable paradigm is low and the barriers large, and more importantly, I think there is a heck of a lot we can/should do without going down that path.

If the government decides to increase funding for community health initiatives, it makes more sense to simply expand the existing infrastructure than it does to invent a whole new provider. We already have NP's, PA's, and CHRN's. The existing entities all have more political pull than EMS, and will quickly snatch up any funding made available. And as a taxpayer who would rather see his tax dollars go towards the actual delivery of care rather than towards funding redundant educational programs, I wouldn't necessarily disagree with that.

Now, that said.....

One of the big problems with paramedic education is that it is still focused solely on life-threatening emergencies even though those requests make up a very small percentage of what paramedics actually do. For that reason, it makes good sense to me that paramedic education and mindset would shift from its emergency focus to one where the importance of basic non-emergency care is increased.

I would re-design paramedic education to take a full two years (at least), and the curriculum would spend at least as much time on non-emergency as on emergency care. Paramedics would still learn to do EKG's and ACLS and PALS and airway management, but rather than pretending that's all there is to prehospital care and then having to schlep everyone to the ED whether or not they need it, medics would also be in a much better position to implement protocols that allowed for "treat and release" and for referral to clinics. Asthma attacks, diabetic wake-ups, minor burns, minor lacerations, and drunks would no longer have to receive the same disposition as a STEMI or a stroke.

And I wouldn't call this a "community health paramedic"; I would just call it a paramedic who is better trained to do what we are already called to do most of the time anyway.

I would much rather see the EMS community get behind the idea of increasing and improving basic educational standards and making them reflect the realities of what paramedics actually do. To me that makes a lot more sense and is a lot more realistic than all the push towards the community health or critical care stuff.

I very much agree, except for a few things. In my limited experience, people won't use the community health resources we have because it takes too long and they have no idea what is available to them. They call 911 out of convenience. How do we solve that? Patient education and paramedics being able to refer to clinics is a start.

This also means that paramedics are being taken out of service to make referrals (patient education always takes me a while, especially since most patients see ems as a quick way to get a room in my area.) I will have to explain the new function of ems and why I am referring instead of satisfying their impatience with getting a doctors appointment, all while (this is the big one) not being reimbursed. Private companies will not go for that. I know many dont like diabetic wake ups because we spend our time and supplies and aren't likely to get paid. I can't imagine this will be any different. That means that there needs to be a change in ems reimbursement.

I'm all for paramedics being educated about the realities of what they'll face and being prepared to handle it, but there are some huge hurdles with getting that to happen, primarily money.

 

[MountainMedic]

Clinic referrals and antibiotics would make my day. Cut transports in half.

I note you have "MD" in your training. I plan to go down the same road in a few years. Ultimately, I think paramedicine needs to progress to the level of nursing so that we're respected as healthcare providers.

 

[Carlos Danger]

I very much agree, except for a few things. In my limited experience, people won't use the community health resources we have because it takes too long and they have no idea what is available to them. They call 911 out of convenience. How do we solve that?

This is exactly why "normal" paramedics need the ability to do non-emergency care, and part of the reason why having dedicated "community health paramedics" is unworkable, IMO:

A patient calls 911 for shortness of breath, just like they do now. A paramedic unit responds emergently, just like they do now.

Once arriving, they do the same assessment they normally would, including an EKG. Their assessment findings point to pneumonia. Their protocol takes into account the assessment findings, age, co-morbidities, etc and indicates that the patient should be triaged to clinic. They make a quick call to med control, who agrees with their plan. They then make a quick call to dispatch, who gives them a time for a clinic appointment the next day (or a followup home visit with a PA or NP from the home-health car agency).

The paramedics give a neb treatment and a course of ABX, tell the patient to drink lots of fluids and call back ASAP if they have worsening SOB, talk for a minute about the importance of smoking cessation, and leave the appointment slip with the patient.

They clear that call and are dispatched to a rollover MVC.

​

This also means that paramedics are being taken out of service to make referrals (patient education always takes me a while, especially since most patients see ems as a quick way to get a room in my area.)

I doubt the scenario I described above would take much more time than driving the patient to the ED and waiting in line, giving report, and getting the patient into a room.

Also, if more transports were triaged as non-emergent and fewer patients required transport to the hospital, you'd probably have less pressure to clear quickly.

while (this is the big one) not being reimbursed. Private companies will not go for that. I know many dont like diabetic wake ups because we spend our time and supplies and aren't likely to get paid. I can't imagine this will be any different. That means that there needs to be a change in ems reimbursement.

There would certainly have to be a reimbursement structure in place, that is true.

It seems like it would be worth it to the receiving hospitals themselves to help finance a program like this, considering how much money it could save them.

 

[Summit]

Stir the pot
...
1. Antibiotics. Pts with sepsis or meningitis should get 2g IV ceftriaxone or cefotaxime prehospitally. Crossover allergy in PCN-allergic pts is around 5%. This is standard of care in other parts of the world, rural and urban. It's easy and harmless. From a non-emergent perspective, I think medics should have basic antibiotic knowledge and be able to prescribe specific antibiotics for simple infections (skin, bacterial pneumonia and pink eye, otitis media, traveler's diarhea, etc.). Heck, I'd even be game for letting medics leave pts with a couple days' worth of Percocet.
...

Antibiotics and Suturing:
First you suggest a typical EMS add-on intervention: an intervention with a critical patient that is hard to screw up and may have critical results. These typify EMS protocol based intervention for providers with a low educational floor. Abx for sepsis is not a primary care type of intervention. The whole reason EMS providers can do most of the things they do with so little education is that they are relatively high potential payoff vs a low relative risk (risk of action vs inaction) over relatively short periods of care if protocols are adhered to. At least... that is how it is supposed to be in theory. Thus, some rural services have a specific prehospital abx protocol.

Primary care is not about critical patients and it is much easier to do more harm than good with primary care patients AND POPULATIONS. That is why a much higher standard of education is required. You jump right on in to treat and release via prescriptive authority for abx and schedule II narcotics... ARE YOU NUTS? That isn't something vo-techs CE classes enable, or even associate degreed providers do. It is not something BSN CHRNs do either. Those are skills limited to physicians and midlevels, and in some states Schedule II cannot be prescribed by a midlevel. Paramedics will NEVER receive even limited prescriptive authority until they have masters degrees, and at that point it is still questionable. The same goes for suturing.

FAST:
Again, this is not a community health intervention and might hold promise for tele-FAST, but on paramedic judgement alone?? Again, graduate level education should be involved here.

Hemmorhagic shock resuscitation:
Your points are nothing new and a service's failure to get-with-the-data is a system issue stemming from medical direction. It is not a community health issue.

Labs:
Paramedics can already draw labs. Justifying an i-Stat though? Debatable... and a lot more educational need here to justify.

 

[Arovetli]

You guys remember the movie Apollo 13? When they ship is stranded and the engineers sit down at the table with a bunch of junk raided from the janitor's closet and figured out how to limp the astronauts home? This is kinda where we are at. A flimsy system was made out of haste and political pressure, it got catapulted out there and then things started going wrong, and we have no real tools to fix it.

We have created a system where a limited resource is being used and abused because it has been proffered up by our government as an unlimited resource, a sacrifice to appease the masses who demand free. Now, I do hold that it is a public trust, and even probably evolved into a concept of a right, that there be access to emergency care. But nowhere in this should we as a society hold that emergency care be free.
Patient education will not fix abuse. Read up on the economic notion of the tragedy of the commons.
At some point we have to either say pay up and subsidize the whole thing, or start saying no and rationing. That is the epic debate raging in Washington, who knows how it will turn out.

So in the meantime, we are left with limited resources to meet a potentially unlimited demand, creating downward pressure on the labor conditions.

I really do support expanding ems education, but realistically placing it at a two year, associate degree level places the field behind the times. the 4 year degree is standard, and is going to be the only way to achieve respect as a professional, competent, stand-alone healthcare provider. But it is not economically feasible to require this level of education, we cant pay commensurate salaries or provide work conditions to match education.

There is immense downward pressure on the wage earnings of medics, because reimbursements are low AND if insurance is going to ever up reimbursements, the political and consumer pressure is to up them for hospitals and doctors and innovation tech companies, not paramedics.

We are on the losing side of economics.

As far as FAST, field abx, field Rx...the more advanced care you introduce into EMS, the more good stuff we give away for free. It's not going to happen unless the whole healthcare system becomes consolidated under the govt. and taxpayers are willing to foot the bill..which is projected to grow to 40% of GDP..and that is utterly unsustainable.

Lets face reality: Our system needs ambulance drivers alot more than it needs paramedics. We need ambulances to provide a logistical purpose of transporting patients at low cost, and we need it badly. Insisting on paramedics on every firetruck, every ambulance, every call keeps the downward pressure on wages strong.

Paramedics are a specialized resource, and we need to act like it, especially if we want it to get better, increased wages, increased scope of practice.

I'm fine with basic EMT training for ambulance attendants, we need vocational/certificate level educated basic responders, CPR/AED etc. to drive ambulances. Fire departments need Advanced EMT to give be able to justify their existence by saying we have ALS on every truck, and its good to provide that extra level of care.

But getting to the level of a paramedic, where we are doing real EKG interpretation, real invasive stuff, higher level drugs and procedures...it either needs to be done away with (which I oppose) or it needs to break off of the concept on being chained to an ambulance and a fire truck on every 911 call. Because right now, paramedics suck at being paramedics, and that is because too little money, too little education, and too many calls. The police dog gets more mandated training than the paramedic.

But hospitals like transports because they get to bill the patient, doctors like transports because they get to bill the patient, and corporate owned ambulance services like transports because they get to bill the patient. Until it becomes economically/financially/politically disadvantageous to take someone to the hospital, everybody is going to the hospital.

So, give them that. Let there be ambulance drivers, and let there be paramedics.

Right now an EMS medical director does so at either 1) an academic center affiliated with the service on salary, or 2) a financial loss. There is not even a decent way to reimburse physicians for their time as medical control. Why are we asking a doctor to provide his consultation services at below market or nonexistent rates? And thus few physicians take a hands on role in EMS. EM right now is obsessed with observation medicine, critical care, and ultrasound....nobody really comes after EMS except more as an interest and a hobby and because it is fun. Relying on altruism and hobby enthusiasm is a terrible plan for EMS success.

It is all about the money and politics.

I am sorry for writing a book, kudos if you read it.

 

[chaz90]

We have created a system where a limited resource is being used and abused because it has been proffered up by our government as an unlimited resource, a sacrifice to appease the masses who demand free. Now, I do hold that it is a public trust, and even probably evolved into a concept of a right, that there be access to emergency care. But nowhere in this should we as a society hold that emergency care be free.
Patient education will not fix abuse. Read up on the economic notion of the tragedy of the commons.
At some point we have to either say pay up and subsidize the whole thing, or start saying no and rationing. That is the epic debate raging in Washington, who knows how it will turn out.

So in the meantime, we are left with limited resources to meet a potentially unlimited demand, creating downward pressure on the labor conditions.

And the people said amen. I have so much more to say on the subject, but it may need to wait as I should probably try to get some sleep.

 

[ExpatMedic0]

Some great points guys. I think its also important to remember we are seeing a lot of new pilot projects pop up, and although the focus of many is rural areas its not the only one. I for one am more interested in seeing it intergraded in urban systems. I think of Community Paramedicine not only as a provider level, but also an abstract concept in these early stages. It has picked up a lot of momentum, funding, and interest, only recently.

Much of what some of you said is true, why not fix what we have which is broken (current Paramedic model and EMS system) before making a new provider. The thing is nothing has done much for that, the NAEMT has proved useless in my eyes for advocating and advancing EMS. The NREMT has been making progress lately, but at to slow of a rate, and we are not reaching objectives from the "EMS Agenda of the future" (if anyone has read it) in timely or effect manner.

What I see community Paramedicine is, our Hail Mary play. It could cause a domino effect in helping EMS better itself in a rapid manner. Not only through increasing education standards and reimbursement, also by having so much international influence and input with the integration of the IRCP (www.ircp.info/) In the bigger picture of things, it gives me hope. Anyone who has been in this business long enough knows we are the red step children and it takes a lot of optimism to stay in EMS as a career.

Paramedics have been replaced in systems where they proved to be inefficient. They where replaced by EMT's and RN's in two systems that come to mind. If we don't find a way to start advancing our education and then proving our existence with results (I.E. empirical data and peer reviewed professional studies) we will either cease to exists in some areas or will remain a vocational trade and not a profession. We need change and we need it now. CP may not have all the answers, but it seems to be a step in the direction.

Just some food for thought is all

 

[ExpatMedic0]

Apologies for the major typos

 

[Arovetli]

I admire your optimism, and I apologize for being such a negative nellie on this issue.

I agree with you wholeheartedly on the utter abysmyl wretched failure of Our Glorious Leaders to lead.

Ultimately it will fall to power, politics, and money. Resources will go where the money is or where the political pressure is greatest or both. I suppose it is tilting at windmills to criticize ideas which may never be.

I would submit to you a quote from the International Rountdtable on Community Paramedics taken from your link: "It is also interesting to note that EMS systems were not seen as part of the primary care continuum until most other options were exhausted."

Or in other words: Nobody else was willing do this job, so we dumped it on the medics.

 

[ExpatMedic0]

Ultimately it will fall to power, politics, and money. Resources will go where the money is or where the political pressure is greatest or both. I suppose it is tilting at windmills to criticize ideas which may never be.

Yes, should it prove to be successful and a money maker, EMS will most likely have to go to battle with bigger more powerful groups like the IAFF, the ANA, maybe even NP's and PA's. However, the guys in film 300 did a hell of a job fighting a superior force, except for the ending..... :blush:

 

[Arovetli]

Yes, should it prove to be successful and a money maker, EMS will most likely have to go to battle with bigger more powerful groups like the IAFF, the ANA, maybe even NP's and PA's. However, the guys in film 300 did a hell of a job fighting a superior force, except for the ending..... :blush:

Friend, I say this with love, but I think people could forget Kilimanjaro and start climbing Mt. Your Optimism. And they would probably never reach the top...

The day I fight a six figures plus a year makin midlevel for an EMS job....

And even the physicians couldn't stop Gen. Mundingers Nurse Army. She's a freakin machine man. Id wager she could make ol Xerxes cry.

 

[chaz90]

Mundinger does indeed make me cry, and her actions don't even directly affect me.

 

[ExpatMedic0]

Just an update on a related article I found today. "How Minnesota got its community medcs paid"

http://www.emsworld.com/article/10913443/how-minnesota-got-its-community-medics-paid

 

[ExpatMedic0]

Update today regarding Honolulu's Community Paramedic Program.

http://www.emsworld.com/news/10953691/honolulu-drops-community-paramedic-program

 

[pcbguy]

Friend, I say this with love, but I think people could forget Kilimanjaro and start climbing Mt. Your Optimism. And they would probably never reach the top...

The day I fight a six figures plus a year makin midlevel for an EMS job....

And even the physicians couldn't stop Gen. Mundingers Nurse Army. She's a freakin machine man. Id wager she could make ol Xerxes cry.

I'm loving this thread!

You hit on one of the biggest issues. EMS still relies on protocols and medical direction. That isn't a problem is the MDs go along with it. It is beneficial to them so it shouldn't be a tough sell.

What does everyone think of the ANA pushback though? Do you think there would be much? It would benefit them also as the traffic to the ED would lower.

I think we are still in the infant stages of EMS and Paramedicine. It's only been around some 40 odd years. I can imagine that nursing had some similar hurdles to jump through when they were in their infancy. On the other hand we have issues today that previous generations never had.

Just more food for thought.

This is one of the best threads ever.