Proposed EMS Scope of Practice Model

[Flight-LP]

These two problems were actually addressed in the proposed scope of practice (allowing EMTs to place IVs and combitubes). I think another 40-50 hours would be sufficient to teach those skills without increasing class times too much.

And this is precisely why it will not pass nationwide. I can teach these skills in about 2 hours, but one cannot truly apply or correlate the didactic knowledge behind WHY these interventions are performed without substantial additional education. If we just allow basics to perform these skills without providing adequate education to support these interventions, we are then being counterproductive. It is difficult to carry yourself as a healthcare professional when you are performing in a counterproductive environment.

Take a moment to search the forum, there are many threads covering this very topic..............Here a recent one for reference.................

http://www.emtlife.com/showthread.php?t=5674

 

[daedalus]

aye!
Most patients who dial 911 do in fact deserve paramedic response.

In my area, we have paramedic/EMT ambulances, our EMTs are trained to assist paramedics in ALS procedures (place the leads in 12L EKG, set up for intubation, spike IV bags, ect). Additionally, our EMTs are trained to monitor simple ECG and provide manuel defib, but only while with a paramedic or RN. This isnt bragging about the extra "skills" we can preform but it effectivley makes us better team players and being a shorter training program, there are EMTs available for the increased patient load in the coming years.

This system, and call me out here if you disagree, seems to work wonderfully. AMR runs these units in my county.

As for age, Rid, you are exactly right. Brain devolopment, especially in the frontal lobe, takes until at least 20 years to fully mature. This wont stop me from being an EMT however, because if I pass the class final, skills final, and the national registry, I have demonstrated that I can effectivley preform my required duties. If the National registry isnt good enough to prove critical thinking ability as it applies to EMS, maybe we should make the National Registry more difficult, theres a thought.

I strongly advocate more difficult and longer EMT programs. Mine was at least 170 hours. I think it should be pushed to 200 and encompass more of the science of medicine. I wouldnt change the scope of practice execpt to add starting IV lines and simple fluids// this includes learning fluids, elctrolytes, and Acid-base balance. There would be more than enough time in an extra 80 hours, which divided by 4 (4 hour classes) is 20 extra classes.

 

[medicdan]

I strongly advocate more difficult and longer EMT programs. Mine was at least 170 hours. I think it should be pushed to 200 and encompass more of the science of medicine. I wouldnt change the scope of practice execpt to add starting IV lines and simple fluids// this includes learning fluids, elctrolytes, and Acid-base balance. There would be more than enough time in an extra 80 hours, which divided by 4 (4 hour classes) is 20 extra classes.

I agree, and one more time defer to the Israeli system. The Hovesh (Medic/EMT) course (200 hours + driving) covers exactly what you mentioned-- starting IVs (only NS), and learning fluids, electrolytes, and Acid/Base Balance but no meds (including no glucogel, albuterol, nitroglycerin or aspirin) Again, the idea being (supported by research), specifically in serious trauma (terrorist attack), the best treatment, (sorry Rid) patient outcome comes with IV fluids and transportation to a trauma center. The reality is, on the scene of a serious attack, you are not going to have a paramedic treat every patient. I will note, a Hovesh cannot initiate an IV without the permission of a paramedic, although often at large attacks, there are blanket orders given for all patients of a certain condition.
Glucometer/Glucogel/Asprin use is limited to Hovesh Bachir (the closest equivalent to EMT-I).
In the additional time in the 200 hour course, students learn in-depth the kinematics of trauma, how to improvise when supplies are low, how to help paramedics (because often at a MCI, you jump in wherever nessecary, and uniquely-Israeli EVOC.
I am all for extended education-- I think 200 hours is the proper amount of time for a Basic course-- but emphasis should be put on further education at some point.

 

[Jolt]

Now I feel like I have to take an EMT-I class just to start at the basic level.

 

[Ridryder911]

These two problems were actually addressed in the proposed scope of practice (allowing EMTs to place IVs and combitubes). I think another 40-50 hours would be sufficient to teach those skills without increasing class times too much.

Hence part of the problem. Those without proper education and training attempt to decide what is needed. Sorry, the problem is simple. Basic EMT (no matter how many hours) is not qualified to assess and determine the extent of ALS versus BLS. Even for the scenarios you described for the ankle injury does not require analgesics? Even in all ER's a patient has to be triage by an RN and MSE performed by a physician or there representative (PA/NP). So yes, higher level then if needed or cleared, may then be treated by lower level of license, not reversed. The Basic curriculum is not developed and in-depth to clear and does not teach detail involved assessments to adequately make clear clinical impressions.

Now, remember when one add hours and advanced procedures... guess what? They are no longer basics, rather they are advanced.

Many services have utilized the "band-aid" system, where all calls are evaluated by a Paramedic, then if determined not warranted is transported by a BLS unit, thus keeping the Paramedic available.

Financially there is very little difference in end budgets of operation between operating ALS with Paramedics and those with BLS and no ALS. Payment differential will make up the difference. Thus, if ALS is needed there is not a delay it is present, if it is not, so be it.

Unless a town or region is very remote or very remote, there is no reason not to have professional EMS or at least utilize such.

R/r 911

 

[ffemt8978]

Unless a town or region is very remote or very remote, there is no reason not to have professional EMS or at least utilize such.

R/r 911

Sure there is...money. Somebody has to pay for it, and not a lot of people will do this for free.

Yes, the public can be educated to know that professional/ALS would be better for them in an emergency, but they tend to vote their pocket books when it comes time to increase their taxes. This is a process that takes years, and there is no guarantee that the public will continue to support such services in the future (especially with the rising costs of health care).

Given our local residents, and our local economy, there is no way the public would foot the bill for the 300-400 thousand dollars it would take to staff our ambulances with full time ALS (this includes the initial equipment purchases), and then continue to fund their salaries for any length of time.

 

[Flight-LP]

kinda reminds me of that Cinderella song "Don't know what you got until its gone"..................................

It is unfortunate that people do not realize the true benefit of professional Paramedic level EMS. Too damn cheap to pay for it, but when its one of their loved ones that die because two EMT Basics couldn't provide the appropriate interventions, they will be the first one's to sue. Sad, truly sad. One lawsuit payout would fund a year's worth of an EMS budget.........................

 

[ffemt8978]

kinda reminds me of that Cinderella song "Don't know what you got until its gone"..................................

It is unfortunate that people do not realize the true benefit of professional Paramedic level EMS. Too damn cheap to pay for it, but when its one of their loved ones that die because two EMT Basics couldn't provide the appropriate interventions, they will be the first one's to sue. Sad, truly sad. One lawsuit payout would fund a year's worth of an EMS budget.........................

I agree with your thought but disagree with you about the lawsuit. There would be no basis for it, provided the local providers followed the appropriate protocols and called for an ALS assist at the appropriate time. Just because you don't have a paramedic in the back of the ambulance is not a valid basis for a lawsuit.

 

[triemal04]

Sure there is...money. Somebody has to pay for it, and not a lot of people will do this for free.

Yes, the public can be educated to know that professional/ALS would be better for them in an emergency, but they tend to vote their pocket books when it comes time to increase their taxes. This is a process that takes years, and there is no guarantee that the public will continue to support such services in the future (especially with the rising costs of health care).

Given our local residents, and our local economy, there is no way the public would foot the bill for the 300-400 thousand dollars it would take to staff our ambulances with full time ALS (this includes the initial equipment purchases), and then continue to fund their salaries for any length of time.

(looking at the original topic) This is where Bledsoe's scope could potentially help things quite a bit. Take the Independant Practice Paramedic; in a rural area where there may only be 200 ambulance calls a year, sure, it's not going to make a lot of fiscal sense to have a fulltime ALS service, and most people probably won't want one anyway. But, put several IPP's there to staff a medic unit AND a local clinic, and that might change things. That way the community really does get the most for what it pays; a fulltime ambulance, and a local clinic for generic problems that don't need transport. Kind of like what's happening in some Canadian provinces.

What Bledsoe has propsed is nice, definetly needs some tweaking, but still head and shoulders above what we've got today. And unfortunately, it'll probably never happen, and would take 20+ years to implement even if it did.

Damnit.

 

[cwolfe059]

combi tubes

Here in WI an EMT-B is allowed to place a tube, but we have to be certified as an EMT-B IV Tech, that is a whole nother class with even more hours. I do belive that we have to take a 40 hour class and have in hospital clinicals. I would not mind placing IV's, but right now I am just not in the market for more school.
Cwolfe

 

[VentMedic]

But, put several IPP's there to staff a medic unit AND a local clinic, and that might change things. That way the community really does get the most for what it pays; a fulltime ambulance, and a local clinic for generic problems that don't need transport. Kind of like what's happening in some Canadian provinces.

What Bledsoe has propsed is nice, definetly needs some tweaking, but still head and shoulders above what we've got today. And unfortunately, it'll probably never happen, and would take 20+ years to implement even if it did.

I've got to chuckle at this (not at you triemal04) after reading thread after thread with people in EMS complaining about not wanting to do BS calls or be stationed anywhere near an ED. And, that is with the crew sleeping nights as well as taking afternoon naps. Now we want them to miss their naps and do clinic type patients?

If we weed out those in EMS or applying to EMS who are not truly serious about medicine, what percentage would we lose?

The purpose is to define first an identity as established by standardized education across the board. The A.S. degree mimimum + and X amount of years of experience for CCT or Flight is long over due at the very least.

I would like the paramedic first to become the very best Mobile Intensive Care Clinician possible before getting fragmented again into too many directions or certifications...again.

 

[triemal04]

I've got to chuckle at this (not at you triemal04) after reading thread after thread with people in EMS complaining about not wanting to do BS calls or be stationed anywhere near an ED. And, that is with the crew sleeping nights as well as taking afternoon naps. Now we want them to miss their naps and do clinic type patients?

If we weed out those in EMS or applying to EMS who are not truly serious about medicine, what percentage would we lose?

The purpose is to define first an identity as established by standardized education across the board. The A.S. degree mimimum + and X amount of years of experience for CCT or Flight is long over due at the very least.

I would like the paramedic first to become the very best Mobile Intensive Care Clinician possible before getting fragmented again into too many directions or certifications...again.

Well...can't say to much to the first part, other than if you increase the standards and training, make it harder to become a paramedic, and ensure that people are actually trained appropriately in the medical science, then most people who are in it just for the thrill will be gone; the ones that are left will be the ones who actually like medicine, like EMS, and like doing patient care. So I don't think there would be much of a complaint about working partially in a clinical setting. Plus, if you look at the proposed scope, not everyone would have to be an IPP; in fact the only ones would probably only be the ones who were willing to take a 4-year program on top of their original cert and experience, which most likely would mean they wouldn't have a problem with a clinic.

You're right though; there would initially be a lot fewer paramedics out there, especially if nobody was grandfathered in; if you didn't have at least an AAS then you had to go back to school. And you know what? I'm ok with that. The people left would really be serious about EMS, as would the people coming in; nobody who did it because they wanted a job at a Fire Dept and went to a medic mill. And with the increased education, increased standards, and hopefully increased quality of the paramedics, the respect given to the profession and professionalism could only increase. (over time...like 20+ years).

I don't see how this is fragmenting anything. Get rid of the vocational paramedic and the specialized and leave the licensed as the minimum, followed by critical care (or whatever it was called) and independant practise. That way everyone starts at the same place, and getting a higher cert would be more of a way to move on to another job, or to provide better care at the current job. And while you're at it remove either the medical responder and increase the educational hours to 450 for an EMT, or get rid of the EMT and leave the medical responder.

Honestly, I'd love to see this get implemented nationwide. Unfortunately, it won't, for a lot of reasons. To many states have their own little EMS fiefdoms, the lack of a national EMS authority, IAFF (much as I hate to say it), lack of schools available to teach to the new standards...and so much more. Not to mention that it wouldn't be prudent to grandfather anyone in, which would mean that there would be very little in the way of paramedics for awhile.

I don't know. This would only help (if done right) but will never get done, at least not anytime soon.