Nurses vs EMT/Paramedics in EMS

[jjesusfreak01]

It's my understanding that the advanced practice paramedics do essentially two things. First, they do welfare checks and other preventative measures to help keep frequent flyers (especially legitimate freq. fliers such as patients who are having trouble controlling their BGL) out of the system by providing home checks.

The second thing they do is they respond to all of the critical calls so that there's a provider who's regularly performing the high risk/low utilization skills and to act as kinda of a director type person to make sure everything that needs to be done is being done.

That is correct.

To clarify, their scope of practice is not much greater than a standard Paramedic in regards to emergency prehospital care. The expanded scope primarily refers to their community paramedicine skills.

 

[EMSLaw]

It's my understanding that the advanced practice paramedics do essentially two things. First, they do welfare checks and other preventative measures to help keep frequent flyers (especially legitimate freq. fliers such as patients who are having trouble controlling their BGL) out of the system by providing home checks.

The second thing they do is they respond to all of the critical calls so that there's a provider who's regularly performing the high risk/low utilization skills and to act as kinda of a director type person to make sure everything that needs to be done is being done.

I used to be very critical of the NJ EMS system - and I still am, to an extent. But my opinion has been changing. I've had some limited exposure to other systems, including all-ALS-all-the-time systems, and it seems that there are significant benefits to the tiered response model.

One of those benefits is that it keeps Paramedic skills sharp. Because our paramedics only respond, at least in theory, to calls that involve actually sick people (for lack of a better way to put it) the use their paramedic-level skills with significantly greater frequency. Rather than intubating once a month, they might intubate once a shift. RSI is reasonably common.

That's not to say the system is perfect, but its the same sort of benefit that the few advanced practice medics see in Wake County.

But for the most significantly high-risk skills, the problem is that there simply isn't frequent call for them. How many crics can an average medic expect to perform in a /career/? In an entire county, there might be one or two cases where that sort of intervention is justified in a given year. Even an advanced paramedic won't be able to keep up on those skills.

The community health aspects of it are interesting, though, and something we really don't do. It's a change in the role of EMS from emergency-based to something else, but that might not be a bad thing.

 

[jjesusfreak01]

My personal opinion is that systems should be placing basics with medics. I know that this is becoming increasingly popular for a few reasons, one being that it is cheaper than running dual medic rigs. A second is that it avoids problems of command structure on calls. A downside will be that the medics will end up treating a lot of BLS patients. I know that won't do anything to keep their advanced skills sharp, but then again, in the smaller EMS systems that have a limited geographic region, you need the medics around for the ALS calls. Another obvious downside is that it will put the basics in the driver's seat for most calls.

I think the greatest benefit though of pairing medics and basics is that it will give the basics a more experienced on the job teacher, and moreover, will also give them a much better starting point if they do go on to be medics.

Any thoughts?

 

[JPINFV]

I used to be very critical of the NJ EMS system - and I still am, to an extent. But my opinion has been changing. I've had some limited exposure to other systems, including all-ALS-all-the-time systems, and it seems that there are significant benefits to the tiered response model.

One of those benefits is that it keeps Paramedic skills sharp. Because our paramedics only respond, at least in theory, to calls that involve actually sick people (for lack of a better way to put it) the use their paramedic-level skills with significantly greater frequency. Rather than intubating once a month, they might intubate once a shift. RSI is reasonably common.

That's not to say the system is perfect, but its the same sort of benefit that the few advanced practice medics see in Wake County.

Here's the problem with US EMS. Yes, there's a handful of low use, high risk benefit procedures that when you need it, you need it and it's important to have at least someone available to respond on calls where there's an increased incidence of the procedure being performed. However, what about all of the other bread and butter interventions paramedic level interventions? Converting SVT? Albuterol treatments? Narcotics? Narcan? Fluids (i.e. sepsis)? The list goes on with interventions that are more often and much less dangerous than crics. I think when the "paramedic oversaturation" arguments are thrown around in truly unsaturated systems (i.e. not having the fire department throw several paramedics on every apparatus, but all ambulances having paramedics) that the tendency to look just at the high risk interventions and not all of the other interventions.

 

[EMSLaw]

Here's the problem with US EMS. Yes, there's a handful of low use, high risk benefit procedures that when you need it, you need it and it's important to have at least someone available to respond on calls where there's an increased incidence of the procedure being performed. However, what about all of the other bread and butter interventions paramedic level interventions? Converting SVT? Albuterol treatments? Narcotics? Narcan? Fluids (i.e. sepsis)? The list goes on with interventions that are more often and much less dangerous than crics. I think when the "paramedic oversaturation" arguments are thrown around in truly unsaturated systems (i.e. not having the fire department throw several paramedics on every apparatus, but all ambulances having paramedics) that the tendency to look just at the high risk interventions and not all of the other interventions.

I think that was my point, though. Paramedics, as far as I can see, get ample opportunity to practice their bread and butter paramedic-level skills. While not every ALS call requires intervention, enough of them do, and are spread among the relatively few paramedic rigs that they stay in practice.

Is there really a benefit to having a paramedic on every ambulance? We get into a lot of shouting matches that usually devolve into "Every patient deserves an ALS assessment" and "EMT-Bs are undereducated/stupid/dangerous." I'd need to see some solid evidence as to the patient outcomes to make a determination either way.