Would you like to be a Primary Care Paramedic?

[SeeNoMore]

While I am new to EMS, and not yet a Paramedic, it seems clear to me that the role of Paramedics, at least for the near future, will have to be totally different than it is today.

While I think there is still a place for Paramedics in Urban Systems, I think the number of Paramedics needed will be very small, limited to highly experienced providers who can intervene in the very few situations where ALS is shown to improve patient outcomes. In addiiton I am sure there is still a place for Parmedics in inter facility and critical care transport.

I think this will be especially true if most BLS units are able to carry and administer epi pens,CPAP, nitro and asa for chest pain and transmit EKGs. This will require an increase in education, but I think it makes more sense that large numbers of Paramedics in any given system.

Does an urban system need Paramedics for the vast majority of trauma calls and cardiac arrests? Do we need intubation by most Paramedics, fluid resucitation in most trauma calls, ACLS drugs etc? It seems unlikely. Unless of course RSI and artificial blood producs are shown to notably improve patient outcomes and even then, the number of Parmamedics will still be smalll.

And so Primary Care Paramedecine is being discussed more often. But I wonder, is this something you would want to do? Especially if it means operating in mostly rural systems? I think a lot of medics are attached to the idea of being part of a urban or semi-urban system and I think the future will be tough for many providers. Personally it's not something I am interested in, and is a primary reason I plan on pursuing nursing insead of prehospital work.

Here is an interesting link that puts together the issue well I think, sort of an overview of the death knell of paramedecine as we know it.

http://rescuemonkey.wordpress.com/2009/04/08/do-we-need-paramedics/

 

[CAOX3]

CAOX3<----Gets popcorn and pulls up chair in anticipation of the fireworks.

 

[SeeNoMore]

Actually you know what, I am really curious about how people feel about this field. Never mind the rest as most of it is in other threads. Not that i am not interested, in fact I would much prefer there to be some compelling proof to the contrary given I am about to enter the field. But there you have it.

Simply, is this a field that appeals to you? Either the rural primary care paramedic or perhaps a type of community primary care paramedic that did not typically deal with emergent situaions. Would this work for you? Excite you? Bore you?

 

[18G]

I respect your position but largely disagree with your suggestions. I feel very safe in saying that there will always be a need for the Paramedic level provider. And even more so in a rural setting versus the urban one that you mention.

Paramedics (and EMS in general) provides care. It's not measured solely by the number of lives saved. EMS triages and is the entry point for so many people into the healthcare system.

ALS does have great effect on many patient conditions that we are called to treat.

- Anaphylaxis
- COPD/Asthma Exacerbations
- Drug Overdoses (opiate and others)
- Head Injuries (preventing hypoxia and hypotension and triages these patients appropriately)
- Post-Resuscitation Care (hypothermia, maintaining B/P, airway control).
- Diabetes (tx of hypo and hyper and patient education)
- Seizures (status)
- Pain Management
- Nausea & Vomiting Control
- CHF / ACS & MI
- And many more conditions.

Think of all the above conditions and take Paramedics out of the picture. The majority of the above groups will have very negative outcomes if you were to take ALS care out of the loop.

Imagine yourself not being able to breathe due to COPD, your also dehydrated, febrile, severely hypoxic, and nauseous. Do you really want to wait 20mins or longer to get to a hospital to get relief? What can a Paramedic do you ask?

Dyspnea = beta-2 agonists and anticholinergic meds. (same as ED)
Severe Hypoxia Refractory to Meds = CPAP or intubation (same as ED).
Dehydration = fluid bolus (same as ED).
Fever = fluids and depending on dyspnea level, acetaminophen (same as ED).
Nausea = ondansetron (same as ED)
Underlying Pathology = Solu-Medrol (same as ED).

The above treatments are very crucial and the earlier delivered the better. This is just one example of what we do in the field that has direct impact on patient condition and outcome.

Your ordinary, everyday Paramedic does play a vital role in patients care and outcomes. Primary Care Paramedicine is an interesting concept and one some EMS systems have explored. Personally, I am not opposed to it and like the idea of expanded scope and dealing with patients that have chronic health problems. I am well passed the all 911, lights and sirens phase. I enjoy taking care of people and making them feel better and allowing them to live their lives as independently and deficit free as possible.

 

[medicRob]

Paramedics in the US refuse to get with the rest of us and get a bachelors education with a proper background in the sciences, mathematics, and humanities. The last thing we need to focus on right now is giving them more skills. First, education. Then, skills.

 

[18G]

Agree with MedicRob. It would be many, many years before you would see a wide-spread deployment of the Primary Care Paramedic model.

What you may see is more specific, alternate care programs being delivered by EMS. For example, DC Fire & EMS have instituted a program where they have crews that routinely check in on certain patients and help the patient in the management of their long-term care which helps avoid taxing 911 response for a non-emergency issue.

 

[SeeNoMore]

I don't disagree overall 18g, but I think the future will see far less Paramedics in a more targeted role. I think that many paramedics will be out of a job, or new medics will have no jobs if we can not find other ways of utilizing our skill set.

But I could not agree more about education.

 

[medicRob]

I don't disagree overall 18g, but I think the future will see far less Paramedics in a more targeted role. I think that many paramedics will be out of a job, or new medics will have no jobs if we can not find other ways of utilizing our skill set.

But I could not agree more about education.

How do you intend to bill this? Sure, you can look toward urgent care billing, but we are in a system where Paramedics are billed by mileage because they are not seen as licensed professionals by the insurance companies. The first step here would be education as well. Once you are seen as licensed professionals by the insurance companies, your services can then be billed as "Paramedic skill hours", not only opening the door to more revenue and higher salaries, but also to the possibility of urgent care billing. In our current system, if you don't transport, you get $0.

I am doing a write up on just such a thing for EMS World Magazine where I outline several benefits of Degree versus certification programs in EMS as a whole. Skill hour billing is one of the points I make. I also speak with regard to making "Community Paramedicine" a specialty choice for 4th year BS, Paramedicine students.

 

[18G]

I don't disagree overall 18g, but I think the future will see far less Paramedics in a more targeted role. I think that many paramedics will be out of a job, or new medics will have no jobs if we can not find other ways of utilizing our skill set.

I'm curious to hear your basis for thinking that Paramedic's will be in less demand.

Communities will always need and desire the ALS level of care. People are not going to stop experiencing medical and traumatic emergencies. People will continue to have MI's, COPD, Seizures, hypoglycemia, crash their cars, etc. The US population has a high number of elderly and that population group is still rising.

I would not worry about Paramedic jobs being in short supply.

 

[MrBrown]

You mean Extended Care Paramedic, a Primary Care Paramedic is what Canada calls thier BLS person

Brown is just going to come right out and say it, American Paramedics are way too undereducated to even have half the tricks they have now, let alone any more.

 

[bigbaldguy]

I'm curious to hear your basis for thinking that Paramedic's will be in less demand.

Just to play devils advocate what about the idea that as technology advances skilled providers will be less needed or at least require less skill training? Think attach a patch and push a button, follow prompts type stuff. There was a time when a pair of shoes had to be made by hand and only a skilled craftsman could make a decent pair but these days you would be hard pressed to find a master cobbler. Just a thought.

 

[medicRob]

I'm curious to hear your basis for thinking that Paramedic's will be in less demand. .

RN's getting so tired of Paramedics whining over the time it takes them to complete what little education they do have, and throwing fits about what education they need, that we take over the profession, changing CTRN from a certification to a specialty area.

/sarcasm <-- kinda

 

[SeeNoMore]

Well for arguments sake, I can not imagine the public has any idea by in large what Paramedics do VS EMT's. As long as someone is showing up in a lighted up truck and taking them to the hospital, well, I imagine that will be enough.

And you could be quite right that there will no be a shortage of need for Paramedics, but perhaps there should be! It would be beyond foolish for me to match my knowledge of EMS with the majority of posters here,but I do know that every single doctor I have ever spoken with, as well as most leading EMS bloggers/writers etc all seem to agree that one of the primary problems with EMS today is the frontloading of Paramedics where EMTs will often suffice, especially if you want to coldy examine the difference in mortality based on ALS vs BLS response.

 

[medicRob]

Well for arguments sake, I can not imagine the public has any idea by in large what Paramedics do VS EMT's. As long as someone is showing up in a lighted up truck and taking them to the hospital, well, I imagine that will be enough.

And you could be quite right that there will no be a shortage of need for Paramedics, but perhaps there should be! It would be beyond foolish for me to match my knowledge of EMS with the majority of posters here,but I do know that every single doctor I have ever spoken with, as well as most leading EMS bloggers/writers etc all seem to agree that one of the primary problems with EMS today is the frontloading of Paramedics where EMTs will often suffice, especially if you want to coldy examine the difference in mortality based on ALS vs BLS response.

Veneficus and Brown, brought up a very valid point. In Western medicine, we haven't really done much for Chronic Disease sufferers other than make them comfortable or do something to take care of the symptoms, but not the underlying condition. Medicine is almost, dare I say... stunted in this area.

 

[18G]

Well for arguments sake, I can not imagine the public has any idea by in large what Paramedics do VS EMT's. As long as someone is showing up in a lighted up truck and taking them to the hospital, well, I imagine that will be enough.

And you could be quite right that there will no be a shortage of need for Paramedics, but perhaps there should be! It would be beyond foolish for me to match my knowledge of EMS with the majority of posters here,but I do know that every single doctor I have ever spoken with, as well as most leading EMS bloggers/writers etc all seem to agree that one of the primary problems with EMS today is the frontloading of Paramedics where EMTs will often suffice, especially if you want to coldy examine the difference in mortality based on ALS vs BLS response.

I agree that the public mostly has no idea about the differences between ALS and BLS. I think if they did they would demand ALS. I strongly disagree that there should be a reduction of ALS. Paramedic should be the minimum level care provider rolling out the door on an ambulance in the US and then build from there.

One can use research and statistics to prove their point and justify their position but decisions should not always be based on a certain statistic or single study. The Paramedic program coordinator at the school I attended (he has since passed away, RIP), worked as a researcher in infectious diseases and one statement he made was, "statistics don't lie, but liars use statistics". So true.

Where are the statistics and research that show overall improvement rates and rates of relieving pain and suffering with ALS care? Again, EMS is not measured solely on mortality rates.

Just because a arm fracture won't kill you, should you be subjected to BLS care only in a bumpy ambulance without pain and nausea management? Since when did making people comfortable become unimportant? An EMT-Basic cannot and should not be administering narcotics.

What about a nausea and vomiting patient? Can they be transported by BLS without any risk of increasing mortality? Of course. But what about the patient's misery. Nausea is one of the worst feelings ever. Why should people not be entitled to relief as early as possible?

Consider the timeline. N&V for a day. 911 gets called.... say 5mins to get to the house. 10-12mins on-scene. Average transport time in sub-urban/rural area about 20mins. Take patient into ED, transfer care, wait for nurse evaluation and then physician orders... depending on ED census... anywhere from 10-20mins or longer. So if BLS transported both patients from above, they would not receive pain meds or an antiemetic and IV fluids for at least an hour from the time 911 is called. That is a long time to be in pain and/or be suffering from severe nausea. Compare that to pain management in say 15mins? Big difference.

It's not all about mortality rates. EMS provides care for the human being as a whole.

 

[Goofy]

Paramedics in the US refuse to get with the rest of us and get a bachelors education with a proper background in the sciences, mathematics, and humanities. The last thing we need to focus on right now is giving them more skills. First, education. Then, skills.

What were you first: a paramedic or an RN?

 

[medicRob]

what were you first: A paramedic or an rn?

rn, bsn

 

[Goofy]

rn, bsn

Cool. So why did you become a paramedic then?

 

[18G]

In Western medicine, we haven't really done much for Chronic Disease sufferers other than make them comfortable or do something to take care of the symptoms

If it's a chronic disease then all you can do is make patients comfortable and make them as symptom free as possible. Until cures are found what more can you do for chronic disease suffers?

 

[8jimi8]

While I am new to EMS, and not yet a Paramedic, it seems clear to me that the role of Paramedics, at least for the near future, will have to be totally different than it is today.

While I think there is still a place for Paramedics in Urban Systems, I think the number of Paramedics needed will be very small, limited to highly experienced providers who can intervene in the very few situations where ALS is shown to improve patient outcomes. In addiiton I am sure there is still a place for Parmedics in inter facility and critical care transport.

I think this will be especially true if most BLS units are able to carry and administer epi pens,CPAP, nitro and asa for chest pain and transmit EKGs. This will require an increase in education, but I think it makes more sense that large numbers of Paramedics in any given system.

Does an urban system need Paramedics for the vast majority of trauma calls and cardiac arrests? Do we need intubation by most Paramedics, fluid resucitation in most trauma calls, ACLS drugs etc? It seems unlikely. Unless of course RSI and artificial blood producs are shown to notably improve patient outcomes and even then, the number of Parmamedics will still be smalll.

And so Primary Care Paramedecine is being discussed more often. But I wonder, is this something you would want to do? Especially if it means operating in mostly rural systems? I think a lot of medics are attached to the idea of being part of a urban or semi-urban system and I think the future will be tough for many providers. Personally it's not something I am interested in, and is a primary reason I plan on pursuing nursing insead of prehospital work.

Here is an interesting link that puts together the issue well I think, sort of an overview of the death knell of paramedecine as we know it.

http://rescuemonkey.wordpress.com/2009/04/08/do-we-need-paramedics/

I wonder how many people are really going to be in to these "b.s." calls that you will be treating as primary care.

2nd If a patient needs "ALS" then they need a hospital. Not many calls are treat and street from an EMS ALS standpoint are there?