Is anyone afraid that Evidence-Based Medicine will kill EMS?

[VentMedic]

they forget to take their beta blockers and get worried when their BP goes to 228/90. You need to know enough to see past things that are non-emergent, do an accurate and detailed assessment and only transport people who really need it. Of course if they demand to go then so be it. Always make them sign a refusal though and give them good medical consultation.

Many paramedics I talk to say, "You don't want to be the paramedic that brings every call to the ER." Maybe sometime, when people obviously aren't in any need of emergency care, you develop rapport with the patient and explain you can take them if they want to go, but everything seems ok. I know its tough to do, but I guess only seasoned medics do this type stuff.

You're kidding, right? You consider this BP nothing to worry about? Was the patient symptomatic? Regardless of it being the patient's fault that they forgot to take their beta-blocker, it is no reason to blow off a situation that may need to be addressed such as a systolic BP of 228. PO beta blockers will not work immediately and if this BP has been sustained for any length of time you shouldn't just tell them to take their pill and call a doctor. If the patient was on beta blockers there is a good chance their BP may have been an issue in the past and this may not be something to write off as BS. Sometimes people who are elderly or even those with various disease processes regardless of age do forget to take their meds. Not everyone is noncompliant or looking to abuse the system. Even if they didn't take their beta blockers because they were "feeling better", that is no reason to cop an attitude with the patient to where it can skew your medical judgment.

Just getting a patient to sign are refusal does not release you from liability especially if you document a systolic BP of 228. Of course if it was only your partner that witnessed you taking the BP, you could lie and say the BP was 128 on your paperwork to justify your nontransport of the patient.

 

[CAOX3]

Yeah why would you worry about an indicator for CVA . We shouldnt be dismissing anyone with signifigant BP elevation.

Im going to give you the benefit of the doubt here and say bad example.

As far as education everyone needs more education, however until its mandated we cant expect providers to just "educate themselves."

I think the problem with evidence based medicine is it takes forever to reach the provider. Something proves effective and ten years later it becomes common practise in EMS. Some systems are proactive and some are not.

One provider, one treatment guideline thats my vote, amount of education is debatable two years or four years. Will I see it in my lifetime nationwide? Not likely.

 

[rhan101277]

You're kidding, right? You consider this BP nothing to worry about? Was the patient symptomatic? Regardless of it being the patient's fault that they forgot to take their beta-blocker, it is no reason to blow off a situation that may need to be addressed such as a systolic BP of 228. PO beta blockers will not work immediately and if this BP has been sustained for any length of time you shouldn't just tell them to take their pill and call a doctor. If the patient was on beta blockers there is a good chance their BP may have been an issue in the past and this may not be something to write off as BS. Sometimes people who are elderly or even those with various disease processes regardless of age do forget to take their meds. Not everyone is noncompliant or looking to abuse the system. Even if they didn't take their beta blockers because they were "feeling better", that is no reason to cop an attitude with the patient to where it can skew your medical judgment.

Just getting a patient to sign are refusal does not release you from liability especially if you document a systolic BP of 228. Of course if it was only your partner that witnessed you taking the BP, you could lie and say the BP was 128 on your paperwork to justify your nontransport of the patient.

Well the c/c was high BP pt had his own home BP machine and got that value I posted earlier. Upon arrival it was 168/84, I am just a student and I was with a preceptor. I noticed a pulse that was not normal, but patient was asymptomatic, medic said patient probably lived with it. I don't know what it could have been since he wasn't hooked up to a monitor but now that I think about it, it may have been sinus arrhythmia.

Seem like his heart would skip a beat during breathing and then normal up, hard to say.

The patient didn't want to go to hospital anyhow.

Where can I got to look at these reports of evidence based medicine results?

 

[VentMedic]

Well the c/c was high BP pt had his own home BP machine and got that value I posted earlier. Upon arrival it was 168/84, I am just a student and I was with a preceptor. I noticed a pulse that was not normal, but patient was asymptomatic, medic said patient probably lived with it. I don't know what it could have been since he wasn't hooked up to a monitor but now that I think about it, it may have been sinus arrhythmia.

Seem like his heart would skip a beat during breathing and then normal up, hard to say.

The patient didn't want to go to hospital anyhow.

I have many more questions about this scenario but back to the topic.

However I will say sometimes the facts in EMS are skewed by the providers which also makes researh difficult. Example: the number of intubation attempts or what even qualifies as an "attempt".

Where can I got to look at these reports of evidence based medicine results?

Since you are a student, the library should have access to the "Prehospital Emergency Care" journal.

http://www.naemsp.org/publications.html

http://www.informaworld.com/smpp/title~db=all~content=t713698281~tab=subscribe?waited=0

http://www.naemsp.org/

http://www.naemsp.org/position.html


Here's a few articles to look up: (Also, look to the right of each article for more articles as well as the references used in each article.)

http://www.ncbi.nlm.nih.gov/pubmed/18379908


http://www.ems.gov/portal/site/ems/...toid=e8e2ae1ea540f110VgnVCM1000002fd17898RCRD

http://www.ems.gov is a good source for information.

 

[MrBrown]

EBM will not kill EMS but it will change it dramatically away from an emergent response capability to an out-of-hospital community health resource.

I truly believe in the next decade or so the Paramedic of today will cease to exist.

We need to stop using the words "life support", "prehospital" and "emergency" as they just foul up the whole damn mess.

Now this might be a bit crystal ballish but here we are already working on a system that will allow ambo's to tap into our national health database and this system exists in parts of Australia and Canada too.

I sincerely hope we will see the death of traditionalist BLS/ILS/ALS, call-taking, firefighter/paramedics and any fire department involvment within my lifetime and I think we will.

 

[CAOX3]

EBM will not kill EMS but it will change it dramatically away from an emergent response capability to an out-of-hospital community health resource..

I truly believe in the next decade or so the Paramedic of today will cease to exist.

We need to stop using the words "life support", "prehospital" and "emergency" as they just foul up the whole damn mess.

Now this might be a bit crystal ballish but here we are already working on a system that will allow ambo's to tap into our national health database and this system exists in parts of Australia and Canada too.

I sincerely hope we will see the death of traditionalist BLS/ILS/ALS, call-taking, firefighter/paramedics and any fire department involvment within my lifetime and I think we will.

Yeah and the AFL CIO is going to allow that . I not to concerned about what color truck you show up in as long as you can handle your business.

Whats wrong with call taking?

And BLS and ALS is a billing detail in my area. We dont have ILS so I dont know what that consists of.

 

[VentMedic]

I sincerely hope we will see the death of traditionalist BLS/ILS/ALS, call-taking, firefighter/paramedics and any fire department involvment within my lifetime and I think we will.

Aahhh a dreamer... I hope you plan on living for many, many more decades. Even the NREMT changes planned it will take at least 10 - 20 years to see any progress with just these relatively minor changes. It is also absurd that accreditation is something to be debated after well over 40 years.

Did you see this article?

http://www.emsresponder.com/features/article.jsp?id=11832&siteSection=18

 

[mycrofft]

For the love of ...and I thought I was full of gas.

1. The biggest factors in big "Change for EMS" will be political and economic, not science.

2. Your response time to the pt, then/plus to the definitve care site, should dictate what measures make sense, then training and materials should follow. More EMTs spread out better, or more hospitals or whatever likewise spread out to minimize response and return times, would mean less ALS necessary.


Delay (of proper defintive tx) plus inability to address the insult (sickness or trauma), times insult, equals death. You can call that Mycrofft's Law. Loitering to get or do anything which will not offset the resultant delay or immediately institute definitve tx (like a succesful Heimlich) lessens survival (Mycrofft's Corollary One). You can do and observe a lot all at once (Corollary Two), shortening delay and so reducing likelihood of death.

Evidence based medicine over the centuries has yielded some of the biggest advances because, when done properly, you are talking science. Why are people afraid of science unless it tips their apple cart?


Well, I am still full of gas.

 

[medichopeful]

The paramedic's job is to stabilize the patient as best as they can so they can be transported to definitive medical care, which is a physician.

Why not raise the education and training given to paramedics so that instead of just stabilizing them, they can start treating them as well?

 

[Smash]

Originally Posted by DrParasite
The paramedic's job is to stabilize the patient as best as they can so they can be transported to definitive medical care, which is a physician.

Why not raise the education and training given to paramedics so that instead of just stabilizing them, they can start treating them as well?

Indeed. And where I work, that is exactly what happens. Definitive care begins from when we arrive. We improve outcomes not just in terms of survival to hospital (which is a bogus measure anyway) but in real terms of survival to discharge and long term neurological outcomes not just for cardiac arrest, but for trauma such as TBI. We improve quality of life for patients and we reduce the cost to the health system and society as a direct result of our practices.

Of course where I work you require 4 years of full time university study and a minimum of 2 years on road consolidation with instructors and senior medics to be able to practice at ALS level. Maybe we could have the same impact with a 6 month course and being let loose with a drug box...

However we seem to have gone somewhat off course here in discussing EBM and gone back to the old battle ground of education/no education/more education/enough education/what-the-heck-is-this-edumacashun-business-anyway?

So! I would like to pose a question to those out there who are still a bit anti-EBM (I know you're out there!)

If not EBM; i.e. if not the "The judicious use of the best current evidence in making decisions about the care of the individual patient... integrating clinical expertise with the best available research evidence" (thank you Dr Sackett), then what?

What is the alternative to EBM? If we are not examining research, doing research, applying research, then what is it we are supposed to base our practice on?

I genuinely am curious, because I am genuinely perplexed at the number of people who seem to be affronted by EBM.

So please, tell me, if not EBM, then what?

 

[zmedic]

People seem to be forgetting about efficiency. For most calls it is way more efficient to handle them at the hospital than trying to do it in the field. Look at a suture call. To show up to a simple laceration you have to asses the patient, stop the bleeding, irrigate the wound, apply your local anesthetic, set up a sterile field, set up good lighting (which may not be easy in someone's house), sew the lac, dress it, update the patient's tetnus shot, and ensure follow up to get the stitches removed and check the wound. And don't forget antibiotics.

So now you have this ALS ambulance that is out of service for, what, 45minutes to an hour, that has to carry suture supplies, addtional medications, sterile drapes etc. The medic needs hours of additional training in antibiotics, suture techniques, local anesthetic use, additional assessment etc. And how many times are they going to get started and realize that there is a possible tendon rupture or maybe a piece of glass and the patient has to be transported anyway? Or you give the antibiotic and leave and the patient has a bad reaction. In the ED the patient's are going to sit there for a few minutes where they can be cared for if they have a reaction. EMS is going to leave when they are done sewing.

The reason why we have hospitals is that it is more efficient to bring the patient to the hospital than to have the doctors making house calls.

Most US medics aren't even close to being ready to handle a call like I described above in the field. And I think most EDs would argue that it isn't worth the massive expendature on training to save them a suture case.

 

[Melclin]

People seem to be forgetting about efficiency. For most calls it is way more efficient to handle them at the hospital than trying to do it in the field. Look at a suture call. To show up to a simple laceration you have to asses the patient, stop the bleeding, irrigate the wound, apply your local anesthetic, set up a sterile field, set up good lighting (which may not be easy in someone's house), sew the lac, dress it, update the patient's tetnus shot, and ensure follow up to get the stitches removed and check the wound. And don't forget antibiotics.

So now you have this ALS ambulance that is out of service for, what, 45minutes to an hour, that has to carry suture supplies, addtional medications, sterile drapes etc. The medic needs hours of additional training in antibiotics, suture techniques, local anesthetic use, additional assessment etc. And how many times are they going to get started and realize that there is a possible tendon rupture or maybe a piece of glass and the patient has to be transported anyway? Or you give the antibiotic and leave and the patient has a bad reaction. In the ED the patient's are going to sit there for a few minutes where they can be cared for if they have a reaction. EMS is going to leave when they are done sewing.

The reason why we have hospitals is that it is more efficient to bring the patient to the hospital than to have the doctors making house calls.

Most US medics aren't even close to being ready to handle a call like I described above in the field. And I think most EDs would argue that it isn't worth the massive expenditure on training to save them a suture case.

That's certainly true of suturing. And most extended care models I'm aware of don't involve normal emergency ambulances doing sutures in the field. It is entirely appropriate for a case like that to go to an ED. However, the models for extended scope I have seen would involve triaging this person to an appropriate level of care to be exactly what you want - efficient. But you then need your paramedics to be educated enough to know if the lac needs a plastics consult and surgery or a simple suture and a few other things, before they can decide on GP or ED. Education, education, edu....

You can't use that inappropriate example and then suggest that extended care models are inefficient. There are a million examples of cases that currently go to ED or are left at home with no care at all (both go on to be an unnecessary burden to other health care professionals), that could easily be dealt with definitively or extensively by paramedics, with the added benefit being that the trip out there was not a waste of time. Efficiency.

 

[Veneficus]

People seem to be forgetting about efficiency. For most calls it is way more efficient to handle them at the hospital than trying to do it in the field. Look at a suture call. To show up to a simple laceration you have to asses the patient, stop the bleeding, irrigate the wound, apply your local anesthetic, set up a sterile field, set up good lighting (which may not be easy in someone's house), sew the lac, dress it, update the patient's tetnus shot, and ensure follow up to get the stitches removed and check the wound. And don't forget antibiotics.

So now you have this ALS ambulance that is out of service for, what, 45minutes to an hour, that has to carry suture supplies, addtional medications, sterile drapes etc. The medic needs hours of additional training in antibiotics, suture techniques, local anesthetic use, additional assessment etc. And how many times are they going to get started and realize that there is a possible tendon rupture or maybe a piece of glass and the patient has to be transported anyway? Or you give the antibiotic and leave and the patient has a bad reaction. In the ED the patient's are going to sit there for a few minutes where they can be cared for if they have a reaction. EMS is going to leave when they are done sewing.

The reason why we have hospitals is that it is more efficient to bring the patient to the hospital than to have the doctors making house calls.

Most US medics aren't even close to being ready to handle a call like I described above in the field. And I think most EDs would argue that it isn't worth the massive expendature on training to save them a suture case.

I agree with what you have said here, but I think it is not a good example of what can or should be accomplished with a more extended scope of EMS practice.

I think the overall goal should not be to add on more procedures providers are performing, but to make sure that somebody who calls is directed to the proper resources.

Emergency care is extremely expensive in the US. With an average wait times in the ED, the absolute outrageous costs associated, and the lack of ability to effectively treat chronic illness on an outpatient basis, simply taking people to the hospital is not financially sustainable.

Obviously I cannot speak for everyones’ local facilities but of the ones I am familiar with. The charity hospital often charges $500 for a non acute ED fee. Add in a Physician charge of $500 plus any diagnostics, and your simple laceration can run you over $1000. The area private hospitals can exceed these costs by 1/3 or more. (The highest in the area 280% more.)

Now I realize that the total bill is rarely collected from even 80% of the patients, some will have insurance that has negotiated a lower rate, some will meet federal poverty guidelines and pay nothing at all, and some will successfully petition the physician to forgo or lower that part of the bill.

With most, and the last number I heard but cannot substantiate, 87% of all US bankruptcies are related to medical expenses, if the number was even 51%, it means if you get sick or hurt and make above federal poverty level, but do not have insurance, (call these people the working poor) it basically equals considerable financial hardship if not outright ruin.

Considering if you show up at the ED for your chronic disease, you will get a repeat of several diagnostics, the usual department and physician bill, and if not admitted, a temporary measure and referral, which may take months for an appointment. Average wait NEJM published a few months ago was 47 days to see a GP. (don’t remember which issue, I read them every week) How many times could that patient wind up repeating this ED sequence prior to an appointment? How many places leave it up to the patient to find their own GP or specialist?

Have you seen exactly how that plays out?
Open up the yellow pages, start calling in order. One of the first questions: “What insurance do you have?” After a while people give up and try to live with the condition until they wind up back in the 911 system. Nothing is being done but the generation of bills for ineffective care.

Even in larger EDs that have on site social services, etc. The emergency department is an extremely ineffective gateway to the healthcare system in the US.

Cost will be the driving factor in EMS expansion, not the efficacy of additional procedures.

 

[fire_911medic]

There was actually an attempt to set up a "paramedic clinic" where people could go for minor things - very similar to the doc in a box deal for urgent treatment clinics. They would work in communication with a dedicated medical director there for reading of basic x-rays etc. It was on the verge of being set up, however, what it was realized later is that they were unable to do so under the current limitations of the scope of practice (within this state, I'm unsure about nationally). If that were expanded to include these options then education would be forced to expand allowing us to provide the services to the community. Granted it wouldn't be done on the truck, but they could be transported to the paramedic clinic for sutures, basic sprains/strains, things like that. I could see the definite benefit to the community as it was quite similar to what we did within our Occ Health clinic - however we performed these functions under direct oversight and with the luxury of having x ray and things on site which I think would have to be required. I don't see any reason we couldn't expand out to cover these.

As far as evidence based medicine, I think much of it has to do with the fact that people are terrified of losing cool to do skills and that we may see the scope of practice tightened to more what is most beneficial for the patient. Also it may force the level of education to be raised - ie class may take longer and a better understanding must be achieved. I think the two will go hand in hand. It's not neccessarily about a sheet of paper, it is about what will be ultimately best for the patient. Yes intubation is a fun skill - I dont argue, and the skill itself typically isn't that difficult. However teaching someone when to intubate and when not to is a little trickier. Also, evidence is already showing that most medics don't do it enough to adequately maintain their skills and so they need to be required to do OR or ER time in order to keep those skills up - but that would require additional initiative on the part of those people to both set up and attend - otherwise I'm all for taking the skill away. I'd rather you not have the skill, than to do it poorly and possibly be detrimental to the patient. That's just one example there are many others. If evidence is pointing that way then we need to adjust our skill set to fix the problem then we will be following the rest of medicine in that we're trying to find the best treatment for the patient. It's not about us, it's all about the patient !

 

[mycrofft]

Finite resources and "definitve" care.

Good point about stretching assets. "Time equals people"; if you have units tied down treating at homes and in parking lots, you need more units. If and when you can send out medical people who can fully engage a pt at the site, treat, then leave the pt there (no transport), thereby effectively extending the hospital to the pt, without the diagnostic and logistic resources of the hospital, THEN you can start calling field work "definitive".

Oh, wait, that was once called "house calls", and that was pretty well killed once we started using xray machines, stat labs, CT scanners.

Field suturing...revisiting the past here. Suturing is the last step (before billing), beforehand you need to clean, debride and sometimes surgically alter the wound. If not, sepsis results. Trauma Medicine 001. Are you prepared to do surgery, no matter how "minor"*, in someone's kitchen or the back of your van? If things get dicey, do you want to explain to the family that "Well, I thought we had it under control, then we decided it realy needed to go to the hospital" (note the substitute use of "we" for "I", and "it" for "your loved one").
"Field EMS" is a means of forestalling death, pain and disablity until definitve (meaning the reasonable best you have) care is possible. This is not counting mobile medical treatment in time of war out in the outback somewhere; you are not Hawkeye and Trapper John, you are not Marcus Welby, you are Johnny and Roy/Squad 51. Drop the "single combat with death" bit and concentrate on what the pt needs, nt what we want to do.

(My bosses once declared they were "going to set up an E.R." at our facility. I said "Great! Where will be lay out the xray, lab, ICU and operating departments?". End of discussion).

The entire discussion of "definitve care", "snatch and run", and "why can't I suture in the field?" are prim examples of why EBM (i.e., "science") is necesary.

http://www.medicine.ox.ac.uk/bandolier/

*"Minor" means it is happening to you, not me.

 

[Outbac1]

I agree with what you have said here, but I think it is not a good example of what can or should be accomplished with a more extended scope of EMS practice.

I think the overall goal should not be to add on more procedures providers are performing, but to make sure that somebody who calls is directed to the proper resources.

Emergency care is extremely expensive in the US. With an average wait times in the ED, the absolute outrageous costs associated, and the lack of ability to effectively treat chronic illness on an outpatient basis, simply taking people to the hospital is not financially sustainable.

Obviously I cannot speak for everyones’ local facilities but of the ones I am familiar with. The charity hospital often charges $500 for a non acute ED fee. Add in a Physician charge of $500 plus any diagnostics, and your simple laceration can run you over $1000. The area private hospitals can exceed these costs by 1/3 or more. (The highest in the area 280% more.)

Now I realize that the total bill is rarely collected from even 80% of the patients, some will have insurance that has negotiated a lower rate, some will meet federal poverty guidelines and pay nothing at all, and some will successfully petition the physician to forgo or lower that part of the bill.

With most, and the last number I heard but cannot substantiate, 87% of all US bankruptcies are related to medical expenses, if the number was even 51%, it means if you get sick or hurt and make above federal poverty level, but do not have insurance, (call these people the working poor) it basically equals considerable financial hardship if not outright ruin.

Considering if you show up at the ED for your chronic disease, you will get a repeat of several diagnostics, the usual department and physician bill, and if not admitted, a temporary measure and referral, which may take months for an appointment. Average wait NEJM published a few months ago was 47 days to see a GP. (don’t remember which issue, I read them every week) How many times could that patient wind up repeating this ED sequence prior to an appointment? How many places leave it up to the patient to find their own GP or specialist?

Have you seen exactly how that plays out?
Open up the yellow pages, start calling in order. One of the first questions: “What insurance do you have?” After a while people give up and try to live with the condition until they wind up back in the 911 system. Nothing is being done but the generation of bills for ineffective care.

Even in larger EDs that have on site social services, etc. The emergency department is an extremely ineffective gateway to the healthcare system in the US.

Cost will be the driving factor in EMS expansion, not the efficacy of additional procedures.

I must admit this is a scenario I am not familiar with. Here in my little corner of Canada you don't pay for ER or Hospital services. Some hospitals in the province have Paramedics working the ER. They do all the triage, and about 90% of the suturing and casting. Inbetween the triage and tx the Dr. assesses the laceration, decides on the tx for it. Cleaning, plastics, antibiotic and follow up. Then leaves to attend another pt. The paramedic then follows the Drs. orders. This frees up the Dr. to see more pts. The pt goes home without an ER bill. Depending on their insurance or gov't coverage they may have to pay all or part of the antibiotic prescription.

 

[VentMedic]

It's great to talk about the future of U.S. EMS as having an expanded scope but what about the immediate future? What can be done to improve QC/QA outcomes or to even get agencies to take monitoring their Paramedics seriously? Those that do are still being pulled down by those who don't. It will be difficult for just a few good agencies and Paramedics to change all of EMS in this country. We've already seen this over the past few decades. I do find it disturbing that we now have "fly cars" with well trained Paramedics doing what many Paramedics at one time had been capable of doing such as intubation, RSI, determining the correct hospital and giving a few medications that are not used everyday. What is being bragged upon as new really is doing what the Paramedic is supposed to be doing. We've also had community service models that existed back into the 80s but fell to the wayside because the majority of Paramedics in those agencies did not want to work clinics or make house calls. Many signed up for the Paramedic program because of prehospital emergency medicine. If they wanted to work clinics and make house calls they could have become an RN or even an LVN which would have been just a couple more months of training than the Paramedic.

EMS must first define itself as to what role it will go with in Emergency Medicine, read the literature and do well in adapting to changes. If they believe strongly in something then they must provide their own evidence that it makes a difference. I seriously doubt if we will hear from Seattle or many of the flight teams that ETI is useless in the field but most will not leave base without alternatives either. It's not about making something obsolete but about finding the best resources to save time, perform safely and get the best patient outcomes. If your agency can not find a way to prove ETI makes a difference because your track record is not up to par with those that can, you either improve or find an alternative that still produces good results.

The same goes for other simple concepts such as IVs. Are the IOs being used first in some areas because of a loss of skill in starting peripheral IVs?

How about 12-Lead ECGs? I recently linked to the AHA survey that there are still many agencies that do not have the capability of doing 12-Lead ECGs. Yet the data is out there that this is important and it has been around since the 80s proving itself. Here is the link again and it states only half of EMS agencies have 12-Leads ECGs on 75% of their trucks.

http://americanheart.mediaroom.com/index.php?s=43&item=677

What about all the medications? 30 meds and even less in a few states are are not always enough. What can be done to show that EMS is ready for the meds that are shown effective in the literature?

Let's take CPAP as another example. It has been around for well over 60 years and has been well studied. There has been technology being used on transport by specialty and flight teams since 1980. Very user friendly equipment has been around well over 10 years for ambulances. Yet, there are still agencies that have not embraced it.

And, we still have many parts of the U.S. that relies only on BLS and there are EMTs that do not want any change to come to their community. The old BLS vs ALS mentality must leave EMS since you should be educated and trained well enough to recognize when to do something and not to do something. It shouldn't be "BLS has always been good enough" since that statement is not appropriate for all and does the community a disservice. Part of the controversy of EBM in EMS has been "we've always done it like that". However, if you can not convince a few people including those who are involved in EMS that the few skills of the Paramedic are important, how are you going to convince anyone that expanding the scope of the Paramedic is a good idea at this time. It would take years to get up to speed with the education requirements and then petition for reimbursement for your services. Look at the NP and the PA. Their education standard is now at Masters and Doctorate with achieving true physician extender status. The Paramedic in no where near that. With bar now at the NP and PA level, why should the public want anything less since both the NP and PA are still way less than MD? Do we want the public to keep settling for less as they do with BLS only EMS in some areas?

The NP and PA already have their community models in action but still must have very strong national and state organizations making their presence known for the right bills to be passed. EMS still does not have a strong national voice with every state and EMS agency having its own agenda. Only the strongest will come out with the funds and reimbursement. Right now the FDs are getting EMS because of national, state and local tax reform. EMS as a whole in the U.S. is still struggling for a true definition of what they do, since it varies from one side of the street to the next, and without it there may be little choice but to place it with the FD which has an identity.

EMS must first show it has what it takes to make the most of the EBM out there to improve outcomes in their own profession right now. EMS must achieve some unity to have a voice for education in a positive way. EMS must stop protecting the low denominators and making excuses for them. The level of EMT should also not be determining the future decisions for the Paramedic.

Getting grand ideas of becoming a true Physician Extender is not going change what is happening right now in EMS. If the Paramedic can not make the best of what they already have to show positive outcomes then why even consider expanding to a scope when the Paramedic is still a long way off from achieving a basic educational standard for what they do now.

Look at the NP and PA.

NP

http://www.aanp.org/AANPCMS2

NP Research and that doesn't include all the articles that have been published for their EBM.
http://www.aanp.org/AANPCMS2/ResearchEducation

PA

http://www.aapa.org/

Emergency Medicine PAs
http://www.sempa.org/

Post grad PA programs
http://www.appap.org/

Look at the doctors now in home health.

Academy of Home Care Physicians
http://www.aahcp.org/

examples of companies:

http://www.physicianshousecalls.com/

http://www.mobiledoctors.com/

http://www.doctorinthefamily.com/

Now what has EMS done in comparison to move forward with the NPs and PAs as well as all the other health care professionals already involved in home and community health? A handful of EMS programs that are making house calls as welfare checks but not really setting a standard for overall education and training requirements are not enough.

 

[VentMedic]

Let's add on a couple more associations that involve health care professionals trying to make a difference. They are involved in getting funding for the patients who can not afford health care.

Case Managers
http://www.cmsa.org/

Social Workers
http://www.socialworkers.org/

Public Health
http://www.apha.org/

In the U.S., funding will still have to be provided to put Paramedics into home health and there will still have to be proof that the Paramedic is qualified for government and tax funding to perform additional skills. Right now petitioning for reimbursement by "professional" status is still foreign to the Paramedic in the U.S. You can argue that the Paramedic can do it cheaper but isn't it also a goal to raise the Paramedic to a professional level? Is cheaper care always the best care if standards that already exist are sacrificed when it comes to the patients? But then again, the FD is keeping and taking over more EMS agencies for a reason here in the U.S.

 

[Veneficus]

Vent,

I am of the mind that the politicians and ultimately the public will start lowering what is being paid as reimbursement for both medicare/medicade as well as tax levies due to the new financial realities.

Basically, the system will crash and when it does, is when the opportunity to change things will come.

When it does there will be an opportunity to make EMS what it could be. I encourage people to get an education before that happens so they are not one of the minimally trained providers holding the bag.

If what is being paid to healthcare facilities and doctors is on the chopping block, how much time before the current "BLS and "ALS" reimbursement is cut?

Without bias, how many fire departments will want to be involved in EMS when it is no longer a revenue stream?

How many private services will still be in business if the current funding levels decrease even 10%?

I agree with all you said in your post. But to add a bit, I think EMS has lost the ability to decide what its own future will be. Change will be decided for it. If I was a nurse or PA I would be beating down the doors in DC showing how superior my education and services I could provide would be. I would start legislating that a RN or PA be the minimum to provide prehospital care and demand just compensation and demonstrate savings with home health and prevention as opposed to just response.

Love 'em or hate 'em they have positioned themselves to be what EMS could have been. All they have to do is reach out and take it.

 

[VentMedic]

Veneficus,

I agree. ALL the other allied health care professions have positioned themselves through education. Physicial Therapy is a leader in and out of the hospital for their services with well documented data that shows they make a difference in the long run for cost effectiveness and patient care even though that are expensive. OT and SLP are right there with them. Respiratory Therapists have introduced a Bill to expand their services in the clinics and home care which includes a Bachelors minimum with Masters preferred to provide these services. They knew a mere two year degree would be laughed at before the Bill was even being presented. Public Health nurses including those involved in school nursing recognize they must require a Bachelors degree. Even the Athletic Trainer established worth many years ago by establishing a Bachelors degree minimum and working under standing orders and directives of a referral base with a medical director.

As far as the FDs, some are taking on the responsibility of EMS for the wrong reasons or without wanting it but find they must in order to keep funds coming in at a minimum to prevent cuts to the FD itself. Health care districts that may operate some hospitals are feeling the pinch as are those who are involved in trauma districts. Combine that with state tax EMS and Fire district reform, you have the public paying an impressive tax bill. The hospitals themselves are lobbying to keep clinics open to relieve their stress of the patients in their ED who would normally go to government funded clinics. We have or had these services already in place and they did work well but with funding cuts, they are vanishishing. Why reinvent something that will take years to come about and has still to prove what differences can be made especially if there are no diagnostic or prescribing privileges associated with it? I do know the other health professions found it was better to ally with a profession that is established with a strong lobbying body to combine resources for common goals for patient care than to go off on their own. Right now EMS still functions on its own island.