National EMS Scope of Practice Model Revision

SandpitMedic

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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.
That's a lot.
I'll respond in time when I've had time.
 

VFlutter

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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.
I agree. I feel the same about most nursing certifications, except CCRN. A true critical care certification should require vetted experience in a critical care environment. If not, it doesn't hold much value in my opinion.

Taking a one year provider and pushing them through a critical care certification course does not create a critical care provider.
 

Carlos Danger

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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.
I agree 100%. Especially with the part that I bolded.

Is placing a chest tube - for example - a fairly simple skill? Yeah, if you do them a lot. But what if you don't? I'm not sure annual practice on a manikin or even a cadaver really qualifies one to perform a critical skill. Crics are an exception because they are truly a do-or-die situation. I think that's exactly why the referring docs in these "band aid station ED" scenarios that we always talk about often don't have everything done that we see done in a higher level receiving facility. I think these docs know their limits and can admit that they aren't really experts in resuscitation and understand that discretion is the better part of valor. Paramedics are often not as good at such se

What does this mean for paramedics performing these types of advanced skills? Well, if they are truly trained and current on the skill, then by all means go for it. But I think that's where this whole thing falls apart. If even a physician staffing an ED can admit that they aren't competent to do something, I think it's a stretch to imagine that a paramedic with a fraction of the the training is competent to do the same skill. Again, this doesn't apply to a paramedic who truly is adequately credentialed in a given procedure, but I think that once you start looking, you'll see that the type of preparation that EMS deems "adequate training" for a given skill is very often well below the level of education that every other advanced clinician has to demonstrate in order to be credentialed to do the same procedure.

I also happen to be of the opinion that a rigorous education in anatomy, physiology, and pathophysiology should be considered a pre-req to training in surgical procedures. Again, only EMS argues against that.
 

SandpitMedic

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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.
I agree with most of what you said, and also agree wholeheartedly with @Remi

I would only argue you point about PAs/NPs in that a PA/NP is not that much farther than a Critical Care Paramedic with years of high volume experience in an emergency setting. Don't jump me just yet for saying that.
I'm not saying that CC medics need a new level of cert or are the same as a PA, nor am I intending to diminish the level of education and profession of advanced practice providers.

My wife is a APRN, and I am friends with many PAs and APRNs. I'm on the PA track myself. That said... you can have a bachelor's degree in liberal arts, biology, or basket weaving, et. al., and wake up one day (having zero medical experience) and go to PA school. Likewise, you can get into an accelerated program from ASN to BSN straight to MSN without any time providing patient care... Boom, now you have providers with zero experience in emergency medicine other than a 3-6 week ER rotation.

Advanced practitioners are primarily trained in family medicine during their graduate studies. Very few specialize in emergency medicine, and furthermore the typical tract includes only one year of didactic training in, again, family/general medicine. That is followed up with one year of clinical rotations; the rest is OTJ training and specialized training.

So why can't baseline for a paramedic degree be at least a year of A&P, basic biology, microbiology, and chemistry?

I've been a proponent of raising the bar on EMS education for some time. I'm topped out save for a BS in EMS (which is of little use). I have all my certs, an associate's degree, FP-C, and most science prerequisites for PA/med school. My best training has been that which I have elected to pursue including critical care and general ed.

Nothing I've learned in virology or general chemistry I or II has helped me in treating a septic patient or a thoracic trauma patient.... just saying.

Practicing medicine with a biology degree and a masters in physician assistant is cool and all, but in our specific field I feel that we could take the same prerequisite coursework and be better for it. Again, I am not knocking PAs, I'm just saying their training in family medicine has zero implications during resuscitation or other emergent critically ill patients. I'd love to be a PA or MD/DO. They are well trained and competent providers in their given specialty and family practice.

Do not misunderstand me; my argument is not against them, rather it is for EMS. EMS needs higher education standards in formal education as well as clinical training. Current standards of most paramedic didactic training flat out sucks. There is barely any A&P, pathology, or human biology involved. This can be mitigated by adding coursework, elimination of non-accredited private schools (medic mills), and increasing responsibilities. In doing that we will create better clinicians and better opportunities for our profession. It would promote growth, longevity, and professionalism in EMS.
 

Carlos Danger

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My wife is a APRN, and I am friends with many PAs and APRNs. I'm on the PA track myself. That said... you can have a bachelor's degree in liberal arts, biology, or basket weaving, et. al., and wake up one day (having zero medical experience) and go to PA school. Likewise, you can get into an accelerated program from ASN to BSN straight to MSN without any time providing patient care... Boom, now you have providers with zero experience in emergency medicine other than a 3-6 week ER rotation.

Except these people by and large aren't working in EM or critical care. They are doing primary care or the non-acute care roles. If they do end up in a critical care role, they'll have substantial additional training and probably not manage sick patients independently for a long time, if ever.

So why can't baseline for a paramedic degree be at least a year of A&P, basic biology, microbiology, and chemistry?
No argument from me on that.

Nothing I've learned in virology or general chemistry I or II has helped me in treating a septic patient or a thoracic trauma patient.... just saying.
Basic, initial sepsis management is pretty straightforward and algorithmic. So is prehospital thoracic trauma management. But what happens after you deliver those patients often requires a much higher level of decision making. That decision making relies on knowledge gained during medical training, and much of what you learn during medical training just won't make a lot of sense - or at least will be much easier to grasp - without basic preparation. Clinical medicine is a lot easier to learn if you have a really good understanding of pathophysiology and pharmacology, which you can only really learn with a basic understanding of chemistry and physiology and virology, which is easier to learn if you've taken microbiology, which builds on biology, etc. It all builds on itself.
 

SandpitMedic

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Sure, you're on to something. I did state in comparison to an emergency setting regarding rescue1's comment about a 6 year educated PA, so no argument- I think we are saying the same things.

Higher education does build on itself. Regardless, formal education should be an integral part of becoming a paramedic as it is for other medical professions, yet still a critical care provider it does not make.

I think we are approaching the same conclusion with different ways of reaching it.
 

rescue1

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Yeah I think we're all basically saying similar things. I wasn't trying to suggest that a freshly minted midlevel provider should be expected to bounce from school directly into an emergency or critical care environment with minimal supervision the way we expect a paramedic to.

All medicine is primarily taught "on the job", from physicians in residency to EMT clinicals and everything in between. My only point, which we're probably all in agreement on, is that without a firm grasp of the science behind it, there's only so much you can learn, regardless of how much experience you have.
 
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taxidriver

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Sorry for reviving this post but I have some insight that I'd like to add. There are states that simply need basics that have a wider scope of practice. I work for a private ems company that works all the 911 calls for a whole city ( don't want to specify which.) nevertheless, it's a poor city and EMS is very active. The city does not have a fire department and it does not have a police department. The county sheriff covers it for law enforcement, a nearby city for fire, and our company covers the medical side of things. When ALS is busy with the "I feel sick" and "I stubbed my toe" calls and a real emergency comes up, what then? We have to fix this on a state by state if not county by county level. Yes, basics here have CPAP, combit/king, IM epi for anaphylaxis and severe respiratory diatesss. But we should be trained to deal with some more complex cardiac emergencies, establish IV access even if only for a small number of drugs, and overall give us the ability to run more calls by ourselves. So many calls that get dispatched with ALS end up being transported with no ALS interventions it makes me cringe. Make the class longer and give us more to work with. Once the 911 system has more confidence in basics and let us run certain calls by ourselves the system will be a lot more efficient.
 

luke_31

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Sorry for reviving this post but I have some insight that I'd like to add. There are states that simply need basics that have a wider scope of practice. I work for a private ems company that works all the 911 calls for a whole city ( don't want to specify which.) nevertheless, it's a poor city and EMS is very active. The city does not have a fire department and it does not have a police department. The county sheriff covers it for law enforcement, a nearby city for fire, and our company covers the medical side of things. When ALS is busy with the "I feel sick" and "I stubbed my toe" calls and a real emergency comes up, what then? We have to fix this on a state by state if not county by county level. Yes, basics here have CPAP, combit/king, IM epi for anaphylaxis and severe respiratory diatesss. But we should be trained to deal with some more complex cardiac emergencies, establish IV access even if only for a small number of drugs, and overall give us the ability to run more calls by ourselves. So many calls that get dispatched with ALS end up being transported with no ALS interventions it makes me cringe. Make the class longer and give us more to work with. Once the 911 system has more confidence in basics and let us run certain calls by ourselves the system will be a lot more efficient.
It's called a tiered dispatch that's what you're looking for. If they have a problem with having enough ALS ambulances, the solution isn't increase the scope of a EMT, it's hire more paramedics or only use advanced EMTs. The scope of practice you are talking about is covered by advanced EMTs.
 

Summit

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taxidriver

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It's called a tiered dispatch that's what you're looking for. If they have a problem with having enough ALS ambulances, the solution isn't increase the scope of a EMT, it's hire more paramedics or only use advanced EMTs. The scope of practice you are talking about is covered by advanced EMTs.
We do a tiered response with medics and basics on a lot of calls simply because you need the extra manpower. However, advanced EMT's are no longer a thing in my county. Hiring more medics is not getting any easier so if the city gets busy it's residence are SOL and I don't think that's fair.
 

VentMonkey

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We do a tiered response with medics and basics on a lot of calls simply because you need the extra manpower. However, advanced EMT's are no longer a thing in my county. Hiring more medics is not getting any easier so if the city gets busy it's residence are SOL and I don't think that's fair.
And? @luke_31 is right. It's a national paramedic shortage. What would a crash course in IV administration and/ or medication administration for your areas basics do to prolong life within your respective region?

You do realize what most paramedics do in the field, procedure-wise, remains in question with regards to being of any use at all to a patients overall quality of life, right?
 

taxidriver

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And? @luke_31 is right. It's a national paramedic shortage. What would a crash course in IV administration and/ or medication administration for your areas basics do to prolong life within your respective region?

You do realize what most paramedics do in the field, procedure-wise, remains in question with regards to being of any use at all to a patients overall quality of life, right?
I'm gonna have to disagree. theres a number of emergencies that I believe basics should have the ability to run themselves. At the very least have the ability to run an arrest by themselves, deal with hypoglycemia, and give a patient fluids. Maybe if you were working the road when there was no ALS to respond to a pedestrian hit by a car because they were dealing with a "sick" patient your opinion would change.
 

DesertMedic66

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I'm gonna have to disagree. theres a number of emergencies that I believe basics should have the ability to run themselves. At the very least have the ability to run an arrest by themselves, deal with hypoglycemia, and give a patient fluids. Maybe if you were working the road when there was no ALS to respond to a pedestrian hit by a car because they were dealing with a "sick" patient your opinion would change.
Using a trauma patient to say why ALS is needed is not the best option. Trauma needs one thing and that is a non-delayed transport to an OR.
 

taxidriver

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Using a trauma patient to say why ALS is needed is not the best option. Trauma needs one thing and that is a non-delayed transport to an OR.
They also need fluid which as a basic I can't provide. I'm not preaching that this needs to be revised on a national level. I'm simply stating that are places in the US that need it.
 

VentMonkey

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@taxidriver your ideas of prehospital medicine are completely naive, ignorant, and convoluted. Try again when you have more experience.
 

taxidriver

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@taxidriver your ideas of prehospital medicine are completely naive, ignorant, and convoluted. Try again when you have more experience.
And you speak as if prehospital medicine is entirely pointless. Why do any of it? Why not just have an empty rig with a stretcher since anything we do in the field won't help a patient at all.
 

Flying

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Woah there. The folks that have responded to you have only implied that trauma in particular needs a particular response, fast transport to definitive care, fluids aren't exactly the priority.

I don't know much about fluid resuscitation myself, but I do know it has come under a lot of scrutiny for various reasons and I'm willing to bet that what you are suggesting is probably along the lines of the Vietnam-era modality, not the fluid-restrictive one that is being touted today.

On top of that the things that you are suggesting that basics ought to be able to do are not benign procedures. Putting fluids into people and anything resembling decent arrest management are not things you can get away with without some sort of formal education, probably at least paramedic level education.
 

luke_31

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And you speak as if prehospital medicine is entirely pointless. Why do any of it? Why not just have an empty rig with a stretcher since anything we do in the field won't help a patient at all.
Statistically in a trauma situation that would be better then an ALS ambulance that stays on scene to get an IV for those precious fluids you are talking about. Oh by the way fluids aren't very important in a trauma and have been shown to increase morbidity and mortality, the same as if you delay transport to the OR. A true trauma patient needs a surgeon and nothing less will make a significant impact on the patient living or dying.
 

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