National EMS Scope of Practice Model Revision

SandpitMedic said:
Some schools are churning out new medics with 0 live intubations. zero. I've heard that from multiple folks in education, yet I don't think in my area it's a thing yet.

Manikin medicine.

ALS-only fire recruiting has really been a detriment to paramedics and the role of a paramedic. But that's another conversation.
Click to expand...
I believe NCTI and Victor Valley are allowing students to only have manikin tubes
 
Remi said:
A good argument can also be made that intubation by paramedics in the vast majority of cases simply isn't necessary. CPAP is everywhere now, and SGA's have improved dramatically. Many paramedics intubate less than 5 times a year, and a large majority intubates less than 10 times a year. That's probably not only well below the threshold needed to maintain competency, but it also indicates that maybe it's a skill that they don't even really need.

Are there exceptions to all the negativity? Of course. Which is why I don't think it should be removed from the paramedic scope of practice across the board.
Click to expand...

Sounds like we need a new level of provider ;), an "Advanced Paramedic," say??

SandpitMedic said:
Some schools are churning out new medics with 0 live intubations. zero. I've heard that from multiple folks in education, and here in my area there is a private school that does not require it.
Click to expand...

Wow, that's profoundly disturbing. Goes back to my point above, I think.
 
VentMonkey said:
I would consider this a sub-topic, elaborate?

Is the greater LV area absolutely flooded with paramedics? If so, do you think a system such as this, coupled with presumably short ETA's to the ED, really needs ETI in their protocols?*

*there, it's still sort of on topic:).
Click to expand...
There are multiple variables.

The flood of people becoming Paramedics simply to gain a firefighting career is not a new thing. However, I'd venture to say that this has caused for-profit schools to try and make a buck on that. Therefore, churning out Paramedics with the least possible competencies they can possibly get away with.

No live intubations required to graduate and become a certified paramedic?!
Either the agenda is to pu$h them through a$ fa$t a$ po$$ible, or to help eliminate pre-hospital intubation in the long game.

I don't believe distance from difinitive care has anything to do with securing an airway. If the patient needs a secure airway, you secure the airway. As a competent provider you should be able to make the call, and if required properly prepare, intubate, manage, and transport the patient. SGA's and other means are available, and should be utilized if necessary.
There are time sensitive emergencies where obviously getting them to the ER quicker is better, but A comes before B comes before C, which you should also be able to do on the road or in flight if required.
 
EpiEMS said:
Sounds like we need a new level of provider ;), an "Advanced Paramedic," say??.
Click to expand...
We do... it's called critical care.
 
SandpitMedic said:
We do... it's called critical care.
Click to expand...

Not part of the National Scope of Practice model - agreed, though, CCP has been is widely adopted as a paramedic plus some skills level.
 
EpiEMS said:
Sounds like we need a new level of provider ;), an "Advanced Paramedic," say??
Click to expand...
Perhaps even a nationally recognized critical care paramedic (CCP) would be sufficient? Then again, we have enough provider levels as it stands now.

What I took away from most from 6 or so months worth of critical care training was more of what I should, or shouldn't be doing as a "standard" street paramedic, and why. The biggest take away I gained personally was what our instructor liked to tell us, which was:

the biggest difference between a paramedic and a critical care paramedic is their critical thinking.

It has so little to do with "cool procedures", and so much more about the when's, where's, and why's they're done, or not. I can certainly see how this may not be everyone's "cup of tea".

Unfortunately, we work in a comparison-driven industry where your story gets trumped by my cooler story, who's then gets trumped by the next persons coolest story. So as usual, how will any of this help us develop and progress?
 
Last edited:
EpiEMS said:
Not part of the National Scope of Practice model - agreed, though, CCP has been is widely adopted as a paramedic plus some skills level.
Click to expand...
I'd say putting in chest tubes could be considered "plus some skills." Lol.

I'd also say it's less about skills and more about the knowledge base. More patho, more pharm, more everything. Not just doing skills, but having a better foundation of knowledge, why we are doing something, the patient's clinical course, and what can we do to improve those factors.

In my opinion, it should be baseline paramedicine.
 
SandpitMedic said:
In my opinion, it should be baseline paramedicine.
Click to expand...
@SandpitMedic you're right, it should be, unfortunately it isn't. And as you've pointed out above, it appears to be going the exact opposite direction in the United States.

As an aside, I don't think chest tubes belong in a non-sterile environment setting (considered a sterile procedure, rightfully so). I think finger thoracotomy's are a sufficient replacement, and needle decompression is still acceptable in most cases.
 
Right, I was just using that as an example of "plus some skills"
Generally, if the patient warrants a chest tube in the field, their outcome isn't likely to be positive anyhow. That'd likely be a hot mess of a patient to begin with.
 
EpiEMS said:
CCP has been is widely adopted as a paramedic plus some skills level.
Click to expand...
As myself and Sandpit eluded to, Ep, I would caution this mental approach to this provider level.

I'm not saying you're insinuating this (I know you're much brighter than that), I would just hate to see a standard paramedic take this approach only to have the same backlash that Sandpit describes with many profit-driven puppy mills known as "paramedic schools".

It would thereby defeat the purpose by having that "specialty cert/ provider level". It's actually the reason for the often debated worth behind such specialty certs (FP-C, CCP-C, etc.) now as they stand.

It's a good reason I personally continue to advocate that newer paramedics get, at minimum, a few years tucked under their belts before they even think about delving into such exams.
 
@VentMonkey, definitely not trying to suggest that CCP is "just more skills" - more that there should be recognition of the specialized (or super-paramedic, if you will) in the National Scope of Practice model, so we can at least acknowledge that there are specializations (or otherwise) above the "standard" paramedic level.

Of course, it is the knowledge (not so much the skills) that specialty providers bring (as @SandpitMedic alludes to) that is most valuable.
 
Right, but as it stands now we apparently have paramedic programs requiring zero live intubations, and "specialty certs" that a recent grad from one of these programs could take in a heartbeat.

Clearly, this country has no clue where it's going with its prehospital providers. And also other providers who think this may encourage super-medics, or a pseudo-mid level.

I don't think that's the case. I can't see any value in an advanced paramedic specialist taking any jobs out of any mid levels hands.

Perhaps other people who actually think there's no value in extending curriculum don't wish to see this field mature into a profession? I really don't know.

I can understand the mindset of those who argue we only perform, or are trained to perform a limited amount of skills in a relatively short timeframe. We were, however, clearly times have changed and we're no longer solely providing a limited amount of skills. It's clearly not the case anymore, I fail to see how it isn't universally seen, or adopted.

My personal opinion is that there is just way too much to gain financially from these programs, so what bare minimums? Well, I suffer by watching the next generation of paramedics fumble, and they'll continue to watch the generation afters theirs do the same. And unfortunately a handful of prudent, intelligent, well-intended providers from each generation doesn't seem to be doing enough good for the viability, or sustainability of the profession.
 
VentMonkey said:
Clearly, this country has no clue where it's going with its prehospital providers.
Click to expand...

When I took my initial EMT course, I thought "hey, this is going to be great - there's the NREMT, there's an EMS office in the federal government, there's scope of practice documents!" Little did I know, there is a patchwork of state law, medical director whim, and service...operational issues. It's a real shame from a systems perspective!

From the individual provider level, it's a mess - as you say!
 
EpiEMS said:
When I took my initial EMT course, I thought "hey, this is going to be great - there's the NREMT, there's an EMS office in the federal government, there's scope of practice documents!" Little did I know, there is a patchwork of state law, medical director whim, and service...operational issues. It's a real shame from a systems perspective!

From the individual provider level, it's a mess - as you say!
Click to expand...
Yep, the trickle down sucks, but where it counts more (legislation) it matters not.
 
Interesting little note: It sounds like EMT use of epinephrine auto-inectors is de-facto national scope. I don't have full access to the journal, but here is a poster from the authors. They note that 17 states require epinephrine on BLS ambulances, and 30 permit it.
 
Hey all:

NAEMSO is asking for input.

I gave my very circumscribed suggestions:

Add epinephrine autoinjector administration (EMS stocked) and hemostatics for EMR; add epinephrine, hemostatics, CPAP, and glucometry for EMT; add CPAP for AEMT
 
SandpitMedic said:
I'd say putting in chest tubes could be considered "plus some skills." Lol.
Click to expand...
That's pretty cool.... but how easy or difficult is it to put in a chest tube? how many times a year is it needed to be done on a live person to maintain competency? And assuming it's a low use / high risk skill, that can save someone's life, will it fall into the same group as intubation?

And to be honest, how often are you putting in a chest tube in an IFT, or a CCT, where one is indicated and hasn't already been placed by the sending facility?
 
DrParasite said:
That's pretty cool.... but how easy or difficult is it to put in a chest tube? how many times a year is it needed to be done on a live person to maintain competency? And assuming it's a low use / high risk skill, that can save someone's life, will it fall into the same group as intubation?

And to be honest, how often are you putting in a chest tube in an IFT, or a CCT, where one is indicated and hasn't already been placed by the sending facility?
Click to expand...
I think just because something is high risk doesn't mean it shouldn't be done. How many chest tubes are going in at ERs? Physicians maintain competency... they're actually fairly simple to do, and there are only a few steps to remember and a few cautions. So long as folks are trained properly and kept proficient by demonstrating on cadavers it's fine.
Adding more skills to the hat serves to progress the profession forward. More importantly, as I said earlier, the knowledge of when to/not perform a skill and why you're doing such is more important than the skill itself.
Doing a physician and advanced practitioner skills in the field as a paramedic (properly) is a huge leap for EMS, a huge leap forwards.

In my opinion, fire based EMS is the problem with such advancements. While some may say that is not germane to this topic, I assure it all comes back to that. I'm in EMS... 95% of my training has been medical/EMS related for the past 9 years or so. A firefighter/paramedic who has the same time on the job would say that 95% of their training was fire/rescue related and 5% EMS.

There are other factors that EMS has which need attention, however that is numero uno.

To the last part of your post, the places we pick up usually end up with us being the highest level of care- not always on paper if you catch my drift. I've seen folks with a lot of letters not know how to do/when to do a 12 lead, withhold epi on anaphylaxis because the patient was tachy, had no idea how to use an IO, insist no blood was needed for an open book pelvic fracture, etc etc.... If anyone is going to be doing a chest tube, it will most likely be me and my partner in my response area regardless of it's a scene or IFT.

Generally it happens once a year, however quarterly you are required to demonstrate the skill, as well as surgical and needle crics.

I'm a fan of advancing EMS. I am not making an attempt at hubris or trying to be tacticool, I simply think that we can be trained and we can be competent. We can begin the same treatments in the field that they will recieve at a difinitive care facility. It doesn't have to stop at the mega code, we could use the same strategy for septic patients, some traumas, breathers, etc.
 
SandpitMedic said:
Adding more skills to the hat serves to progress the profession forward. More importantly, as I said earlier, the knowledge of when to/not perform a skill and why you're doing such is more important than the skill itself.
Doing a physician and advanced practitioner skills in the field as a paramedic (properly) is a huge leap for EMS, a huge leap forwards.
Click to expand...

While I agree with most of what you said, I've never been a huge fan of the "keep adding more skills" plan for improving EMS. I would argue that most American paramedics don't even have the pharm/physio/pathophys education for the skills that they currently perform (those medic mills at the top of the page being good examples). So while I agree that doing advanced skills properly is a huge leap forward, I would argue that its a better leap forward if we can have the education to make the best use of our current skillset. Perhaps I'm more cynical than you about paramedic education in the US though. A part of my brain says that if we keep adding skills, we'll end up with paramedics operating at the level of a PA/NP, but with an associates degree instead of 6 years of education.

As a second point, I think that simply beginning definitive treatment in the field is not always as cut and dry as it appears. Therapeutic hypothermia is relatively effective when performed in a hospital, and ineffective when performed in an ambulance. This makes me suspicious of prehospital antibiotic administration for sepsis, for example. Not because I think paramedics can't give antibiotics, but because I find that we're very quick to jump on cool new things before we really know how effective it is.

I don't say these things to crap on EMS or to suggest that the scope of practice should be limited, just that I think we take things slowly, with the exception of increased education, which I think should be our #1 (or at least very high) priority.


Also these thoughts don't apply as much to critical care/HEMS stuff. I've worked in rural (I'm guessing) areas like you described in your post and am aware of the inexperience that a lot of the physicians there have with critical patients. I have minimal experience with CC transports, so I'd be talking out of my *** there anyway.
 
You must log in or register to reply here.
Back
Top