NAEMT Survey and Future Scope of Practice Paper

[Jambi]

The NAEMT has put a survey. They are interested in hearing from individual EMTs, Paramedics, First Responders, Nurses, Docs, and others involved in EMS healthcare. Before you take the survey, they recommend you read the "THE NATIONAL EMS SCOPE OF PRACTICE MODEL" draft. as the survey asks for your thoughts and opinions reguarding the paper.

THE NATIONAL EMS SCOPE OF PRACTICE MODEL PAPER

The Survey

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Members don't see this ad.

 

[12R34Y]

transvenous pacing!?, wound closure?!, central line insertion?!.

you have got to be bloody kidding me?

being a long time paramedic and current 3rd year medical student I can only smile.

I've got an image in my head...........paramedic in someone's house, dawing sterile gown and gloves, laying out sterile field, deciding which central access site is appropriate.........floating a transvenous pacemaker!!

anyone else find this just a tad bit unrealistic and SUPER DUPER expensive. our company complained if you used too many sharps containers.

how are they going to afford to stock suture materials, local anesthetics, central line trays, sterile gowns, gloves etc....that's just plain crazy talk.

curious as to what others think.

later

 

[Febrifuge]

Yeah, I filled out the survey with LOTS of comments.

They describe this new, fancy deep-dish ninja Advanced Paramedic Practitioner as having a relationship with the Medical Director doc as "like" a PA/ doc relationship. Funny, because I was thinking more along the lines of, uhh, gee this is embarassing but how about it be a PA? I understand it's not all big cities like where I live, and more advanced care in the sticks is a real need. But few of the medics I know would want to deal with the legal hassles, the malpractice, etc. Plus, paying for supplies is bad enough but how about the poor schmuck's salary?

No, our hypothetical friend the one-man (or -woman) trauma team deserves better than the unanswered questions between the lines of the report. Any medic who can stomach the pains and complications of more training and more responsibility has my unyielding support and esteem... but they seem to all want to go to med school or PA school. Weird, huh?

 

[12R34Y]

I'm also curious as to how they would find an institution that would be willing to let paramedics place central lines (all of the different approaches and sites). they would need to become proficient ie. NOT just placing one. They would need to place many to do it well and fairly quickly. Otherwise what is the point if it isn't fast. Interns in almost every specialty line up for those procedures and I'm guessing the paramedic would fall somewhere past the resident, intern, CRNA student etc.....good luck getting any practice.

i still can't believe some of the proposed ideas.


later

 

[12R34Y]

oh, i forgot to add that the paramedic would also have to club the PA student and medical students for such a procedure.

they would probably be fighting with cardiology fellows over floating transvenous pacemakers.

i know who'll win that fight.

later

 

[rn29306]

I can't believe the central line arguement as how they have adult sternal IO access kits but maybe it doesn't work well on some populations. Not that they are cheap by any means, they now have an esophageal stethescope (for the OR) that doubles as a pacer seeing how it is so close to the heart and simple to put in, alot better to cram a flexible tube down grandma's oral cavity (in addition to that OETT) than to give her a pneumo from IJ or SC introducer attempts.
Now if only the Lifepaks would accomodate the esophageal pacers.....
Hey a Lifepak model 25 coming to a Gall's near you...

Seriously, if anyone has reasons why the sternal IO isn't a down and dirty way to gain central access in the field, I would like to hear it. I know that the sterility isn't the best in the world and osteo (esp sternal) infection is nothing to laugh at, but you guys know how it goes out there in the ditches.

rn29306

 

[Blue128K]

I found the Advanced Practice Paramedic completely unneeded and un realistic. If they want to add a level to benefit EMS and make it more efficient and beneficial, they need to have a level between EMT and Paramedic....i know some states have EMT-Intermediate, but ours doesn't. The majority of our ambulance services have an ALS/BLS team (Medic and EMT) per ambulance, which is ok on nonemergency calls, but ineffective on serious emergencies such as cardiac arrests, serious vehicle accidents, etc. Also there is a serious shortage of paramedics where I live...an EMT-Int. level would seriously benefit everyone involved.

 

[oudoc08]

After reading the posts above, I was initially leaning towards disapproval of the nature of the advanced practice paramedic. Then I read the article, and have come to the conclusion that many of you have not.

The stated purpose of the article implies that the need for such designation is for placement into areas which may not otherwise be serviced by a physician, but may require skills and more importantly, a higher degree of education concerning the appropriateness of referal. (i.e. - I'm on an oil rig in the middle of the gulf of mexico. I have a man with moderate avulsion injury. Do I need to send him out on a helicopter for an ER/ortho consult, or can I X-ray, debride, close, drain and monitor the wound on site w/ appropriate AB therapy administered. Given the loss of productive work time on a site which may be impacted by loss of a worker, cost of helo, loss of income to worker, higher cost of an onsite physician, etc., such an implement may be appropriate.

Nowhere in the article did I see references to placing central lines in houses, etc.

It is my personal opinion that many of you here who were paramedics in the past, and are now medical students who think you're God, need to remember that evolution of prehospital medicine was dampened inappropriately at times, by like-minded individuals, at the expense of patient care. It was not long ago, that defibrillation was a physician-only skill, and the thought of allowing a EMT or paramedic to perform such a "daunting" task was laughable. How many lives were lost in the interim, due to such attitudes?

Of course there must be appropriate limits on scope of practice, but I don't think any of the procedures or skills mentioned, when implemented appropriately, in any way jeporadize patient safety or the integrity of the healthcare system. Do I believe that transvenous pacing should be attempted in the middle of Oklahoma City enroute to the hospital. Absolutely not. Do I believe it could be beneficial and livesaving in the four corners area of rural New Mexico where the nearest hospital is more than 2 hours away? Absolutely.

I spent seven years as a paramedic before entering medical school, and while I have seen quite clearly the didactic difference in basic science education that is the foundation for theoretical medicine, that doesn't in any fashion qualify me, or any of you, to place knee-jerk limitations on technical skills performed by qualified paramedics. Your role is to work as part of a comprehesive team to ensure the best good for the most people. That includes health care providers of a lower education level than yourselves.

To smugly place yourself on a higher plane simply because you now consider yourselves "members of the club", is deplorable, and I would urge you to promptly remove your ego from somewhere proximal to the pectinate line, and look towards the rapidly evolving future of medicine.

 

[FoughtFyr]

After reading the posts above, I was initially leaning towards disapproval of the nature of the advanced practice paramedic. Then I read the article, and have come to the conclusion that many of you have not.

The stated purpose of the article implies that the need for such designation is for placement into areas which may not otherwise be serviced by a physician, but may require skills and more importantly, a higher degree of education concerning the appropriateness of referal. (i.e. - I'm on an oil rig in the middle of the gulf of mexico. I have a man with moderate avulsion injury. Do I need to send him out on a helicopter for an ER/ortho consult, or can I X-ray, debride, close, drain and monitor the wound on site w/ appropriate AB therapy administered. Given the loss of productive work time on a site which may be impacted by loss of a worker, cost of helo, loss of income to worker, higher cost of an onsite physician, etc., such an implement may be appropriate.

And where will these skills be maintained between the rare call on the oil rig? How much training will be required to demonstrate proficiency? How exactly will that training be different than what an EM trained PA undergoes?

Nowhere in the article did I see references to placing central lines in houses, etc.

It is my personal opinion that many of you here who were paramedics in the past, and are now medical students who think you're God, need to remember that evolution of prehospital medicine was dampened inappropriately at times, by like-minded individuals, at the expense of patient care. It was not long ago, that defibrillation was a physician-only skill, and the thought of allowing a EMT or paramedic to perform such a "daunting" task was laughable. How many lives were lost in the interim, due to such attitudes?

Daunting is different than requiring sterile fields and appropriate back-up services in case of iatrogenic injury. There is a line, and I am not sure where it lay, when the need to transfer rapidly to a full service medical facility outweighs the need (or ability) to perform a procedure "in the field". A great example is pericariocentisis. I worked in an EMS system that, at one time, allowed this procedure to be performed by paramedics. After five years, the procedure had been performed three times. None of those patients actually required the procedure. Of the three, one patient died later from complications of the MI he had actually been having. Transport was delayed for the attempt. More importantly, no cases where prehospital pericadiocentisis was needed were found. So, we have a procedure for which the need is questionable, the chance for iatrogenic injury is high, and performance will delay transport. End result? The protocol was pulled. As a former medic, and municipal EMS consultant, I agree with you, we need to remember our roots. But we, that is EMS as a whole, however, need to be guided by science and sound public health principles, not anecdotal "what if / worst case" scenarios.

Of course there must be appropriate limits on scope of practice, but I don't think any of the procedures or skills mentioned, when implemented appropriately, in any way jeporadize patient safety or the integrity of the healthcare system. Do I believe that transvenous pacing should be attempted in the middle of Oklahoma City enroute to the hospital. Absolutely not. Do I believe it could be beneficial and livesaving in the four corners area of rural New Mexico where the nearest hospital is more than 2 hours away? Absolutely.

Assuming the operators somehow remain proficient...

I spent seven years as a paramedic before entering medical school, and while I have seen quite clearly the didactic difference in basic science education that is the foundation for theoretical medicine, that doesn't in any fashion qualify me, or any of you, to place knee-jerk limitations on technical skills performed by qualified paramedics. Your role is to work as part of a comprehesive team to ensure the best good for the most people. That includes health care providers of a lower education level than yourselves.

To smugly place yourself on a higher plane simply because you now consider yourselves "members of the club", is deplorable, and I would urge you to promptly remove your ego from somewhere proximal to the pectinate line, and look towards the rapidly evolving future of medicine.

Well, I think we disargee on the future scope of EMS, but I agree with your sentiment.

- H

 

[12R34Y]

I stand by what I said.

I in know way believe I am "a god". I will die a paramedic.. I love EMS with a passion. I plan on being very active in pre-hospital medicine as an EM physician and am currently doing research in the pre-hospital arena.

So, I'd thank you osudoc to not lump me into some group of "god" that are medical students.

The skills you are referring to on an oil rig sound like the skill set of a PA at least. Interpreting x-rays, determining the need for a consult on an avulsion injury? putting in drains? Do you realize how much additional training money is going to be wasted on that kind of curriculum?

Gaining competency in those types of scenarios would be virtually impossible.

I'm curious as to why you think your viewpoint is so enlightened osudoc and mine is invalid? I think I have a right to my opinion on this matter as I am a paramedic/medical student.

later

 

[oudoc08]

I stand by what I said.

I in know way believe I am "a god". I will die a paramedic.. I love EMS with a passion. I plan on being very active in pre-hospital medicine as an EM physician and am currently doing research in the pre-hospital arena.

So, I'd thank you osudoc to not lump me into some group of "god" that are medical students.

The skills you are referring to on an oil rig sound like the skill set of a PA at least. Interpreting x-rays, determining the need for a consult on an avulsion injury? putting in drains? Do you realize how much additional training money is going to be wasted on that kind of curriculum?

Gaining competency in those types of scenarios would be virtually impossible.

I'm curious as to why you think your viewpoint is so enlightened osudoc and mine is invalid? I think I have a right to my opinion on this matter as I am a paramedic/medical student.

later

No I don't know how much additional training money is going to be "wasted" on a new curriculum. Why don't you enlighten me?

I've never been under the impression that more education is a bad thing.
What is irresponsible is to allow or encourage an increased level of practice without additional formal education.

Were the highest level of prehospital care to be that of the EMT-Basic, would you insinuate that to advance the level of training to include such invasive procedures as IV therapy and endotracheal intubation would be irresponsible and unjustified? How about "oh my gosh" actually hooking up heart monitors and pushing, dare I say, drugs through their IV. What about placing sternal IO lines, surgical airways, thrombolytic therapy?

Do you see how just 15 or 20 years ago, many many people held the same attitude as yourself, however with the advent of increased education (almost double that of when I went to paramedic school just 10 short years ago), there is more theoretical didactic educational basis to begin to allow paramedics to start to slough the concrete label of "technician" and begin to adopt that of "practitioner". I forsee EMS to adopt a masters program in such, as the nursing field has.

Evolution in action.

 

[oudoc08]

See, even an EMT can do it.


Woman C-Sections Dying Chihuahua, Saves Puppies
Wednesday, December 01, 2004

CEDAR CITY, Utah — A quick-thinking EMT performed a Caesarean section on her dead Chihuahua to save the lives of three puppies.

Carolyn Shaw was at work two weeks ago when she received a call from her husband, saying their long-haired Chihuahua (search), Annie, was in labor and whimpering under the bed.

Shaw asked her ambulance partner Kori Baker, who also is her daughter-in-law, and a student intern riding along if they could stop by the house and check on the dog.

"After I did a quick check I realized she was dead," Barker said.

Shaw's instincts as an EMT (search) and nurse kicked in. She pulled out her stethoscope and listened to Annie's heart to search for some sign of life. There was no heartbeat but there was movement.

"I felt the babies moving inside of her," Shaw said.

Shaw rushed her pet into the kitchen with Barker and the student right behind.

"After she grabbed the knife I knew what she had in mind so I grabbed a few towels out of the drawer and handed one to the student," Barker said.

 

[12R34Y]

And despite all of these WONDERFUL prehospital things that can now be done the mortality rate for ALS v.s. BLS is not statistically significant.

Some studies are now actually showing that prehospital intubation for head injured intubations worsens their outcome.

It all comes down to rapid transport and good BLS care. The fancier you get the longer your scene times and I think most would agree the worse outcomes.

Less is definately more when it comes to prehospital care.

later

 

[oudoc08]

And despite all of these WONDERFUL prehospital things that can now be done the mortality rate for ALS v.s. BLS is not statistically significant.

Some studies are now actually showing that prehospital intubation for head injured intubations worsens their outcome.

It all comes down to rapid transport and good BLS care. The fancier you get the longer your scene times and I think most would agree the worse outcomes.

Less is definately more when it comes to prehospital care.

later

I respectfully disagree with your premise. While I agree that that advanced treatment is useless when the ABC's are ignored, it is absolutely ridiculous to believe that ALS is somehow insignificant. Let me provide you with a few examples, some common, others less so.

1. Beta agonists for bronchospasm. Please try telling your crashing asthmatic patient that oxygen is enough. "I'm sorry, ma'am, but I don't believe that the albuterol, epinephrine, methylprednisolone, iv fluids, and intubation equipment I have here in my ambulance are going to help." Let's see you pull that one out in court.

2. "I'm sorry, your honor, but I think I read somewhere that decompressing a tension pneumothorax somehow wasn't statistically significant."

3. "I know, officer. I know the combative unresponsive guy on the floor that just got hit in the head with a baseball bat is puking all over himself, but "Some studies are now actually showing that prehospital intubation for head injured intubations worsens their outcome. "
I think I'll just roll him on his side and hope he doesn't aspirate or further risk a c-spine injury. Paralytics? No sir, not me. I'd rather tie him down with restraints. Who cares if his intercranial pressure shoots through the roof. At least it wasn't because of that damn ET intubation."

4. "Surgical airways don't make a difference, because darn it, if you can't get it out with the Heimlich, then statistically it didn't need to come out anyway"

I'm bored. You get the point. A patient not in emergent need of a OR, benefits from EARLY treatment, not early transport. While some rookie medics subscribe to the idea of grabbing their code patient off the bedroom floor, flinging him on the cot, running to the ambulance, and screaming off to the hospital,
I on the other hand, find the patient, calmly begin the code, defib, intubate the patient, admin. 1st line medications, and get them to a point to where I feel a few minute break in the code is safe. I then move them to the cot, to the ambulance, work for a little bit, and then have a nice easy ride to the hospital.
When everything necessary for patient care is available in the prehospital setting, it is idiotic and glaringly demonstrates a newbie paramedic's lack of confidence to be running off to the hospital like a madman with every call.

You seem by your posts to have a common sense approach to EMS, but strangely enough, I, who have always considered myself very conservative in treatment (i.e. - I don't like to use alot of procedures, give medications, etc. w/o definite warrant), am taken aback by your ULTRA conservative approach. What you seem to have a disconnect on is that conservatism and an aggressive approach to emergent care are not mutually exclusive. I'm not sure if you're one of these old burnt out medics whose personal experience had led you to believe that nothing you do really makes much of a difference anyway, so what the hell, or if you have just a concrete definition of what EMS is at this point in time. Regardless, if you're planning on pursuing emergency medicine, I hope for your patients, that you adapt a little. In that 7 years in between MS1 and PGY-3, alot will have changed since you last worked street shifts, and if you don't learn to be a little more progressive, you're not going to be real popular with the medics who work under your control. Whether or not that bothers you, I don't know. But, then again, why did you get into medicine in the first place?

Actually, I'm rather interested to see some of these studies that says that ALS isn't statistically significant in patient mortality. Giving you the benefit of the doubt, that to be referencing them, you've obviously read them, please post links to them here so that we proactive thinkers can be "enlightened".

 

[12R34Y]

First of all. The paramedics, EMT's and first responders that I instruct (currently) like me just fine. I'd appreciate you not getting personal. You seem to have done that starting with your first response.

You asked for studies ..........here you go. I tried to throw in several RCT, multicenter trials. several retrospective, prospective etc.....many prominent journals and many in recent years. oh, and there is PLENTY more actual research data to back up what i'm saying. You are telling theoretical stories and not backing them up.

here you go......

Eckstein M. Effect of Prehospital Advanced Life Support on Outcomes of Major Trauma Patients. J Trauma 48: 643, 2000.

9451 patients in LA county that showed expeditious ALS had no impact on survival.



Potter D. A Controlled Trial of Prehospital Advanced Life Support in Trauma. Ann Emerg Med 17:582, 1988.

472 ALS vs 589 BLS in Australia improved 24-hour survival, NO impact on mortality.



Liberman M. Multicenter Canadian Study of Prehospital Trauma Care. Ann Surg 237:153, 2003.

No survival benefit for ALS.



Branas CC. Urban Trauma Transport of Assaulted Patients Using Nonmedical Personnel. Acad Emerg Med 2:486, 1995.

2108 paramedics v.s. 1356 non-paramedics. No survival benefit for paramedics.



Liberman M. Advanced or Basic Life Support for Trauma: Meta-Analysis and Critical Review of Literature. J Trauma 49:584, 2000.

15 studies comparing ALS vs. BLS mortality and OR for dying with ALS 2.6 compared to BLS.




Fowler R, Pepe PE. Prehospital Care of the Patient with Major Trauma. Emerg Med Clin North Am 20: 953, 2002.

No clear role for ALS in trauma.




Turner J. A Randomized Controlled Trial of Prehospital Intravenous Fluid replacement therapy in serious trauma. Health Tech Assess 2000, Vol. 4

1309 patients, there were 2 arms. Prehospital IVF v.s. none.

Scene time 12-13 minutes longer with IVF.




Petri RW. Prehosp Disaster Med 10:43, 1995.

5215 patients with Inury severeity scores greater than 10.
No impact of PHT up to 90 minutes.




Murray JM. Prehospital Intubations in Patients with Severe Head Injury. J Trauma 49: 1065, 2000.

852 patients, GCS 8 or less, in LA county-USC

ETI v.s. non-ETI

Mortality 80% in ETI v.s. 43 % in non-ETI (adjusted for injury severity).




Davis DP. Prehospital Intubations in Patients with Severe Head Inury. J Trauma 49: 1065, 2000.

Prospective study of paramedic RSI in San Diego

209 patients ETI, GCS 8 or less

Increased mortality with ETI 33% v.s. 24%.



Turner J. A Randomized Controlled Trial of Prehospitalal IVF Replacement Therapy in Serious Trauma. Health Technology Assessment 4:iii, 2000.

1309 blunt patients, deaths or Hospital LOS 3 days

Prehospital IVF v.s. no IVF

No difference in survival.

 

[oudoc08]

12R34Y,
Actually, I never mentioned you in my first response. I'm sorry you feel that I have gotten personal. And, I most certainly never said I didn't like you. I'm just a republican, fairly conservative, and very matter-of-fact. If that comes out as brash, then it wouldn't be the first time. There were several other posters besides you, and I was not pointing you out specifially. However, you chose to respond back with points which warranted pointed repudiation. For example in your last post. Your point would be valid were it not for the fact that the studies that you posted were all related to ALS vs. BLS prehospital treatment of trauma. Apples to oranges. The original intent of this thread was to generate response to the theoretical scope of the advanced practice paramedic, not to debate on-scene trauma care. The intended scope of the advance practice paramedic (as is the current paramedic level) is overwhelmingly MEDICAL not traumatic. If I remember correctly, there was little advancement in the traumatic procedural skills (outside of perhaps thoracostomy and peri-mortem c-section)
Somewhere in the last post, you have turned this into a trauma symposium. I don't doubt the validity of those studies. It is through similar studies, that we learned of the detrimental effects of aggressive fluid resuscitation in penetrating chest trauma and closed head injury. We also learned that perhaps MAST was killing as many as it was saving.

However, you must agree that your initial knee-jerk reaction to the thread was based upon what medical procedures could be performed outside of a hospital setting. Let's see, here's a quote which shows that the article was taken out of context.

I've got an image in my head...........paramedic in someone's house, dawing sterile gown and gloves, laying out sterile field, deciding which central access site is appropriate.........floating a transvenous pacemaker!!

Nowhere in the article does it even come close to insinuating this. So, tell me, since you're so pro-EMS, how and why does one take an article out-of-context in a such a manner? The image in your head, is obviously one that you've thought up, certainly not one derived from the scope article.

Again, I fully agree with you on the points made in your last post, but it seems to me that you're spinning away from your initial argument and trying to make it seem as though I somehow advocate spending 30 minutes starting a central line in downtown Oklahoma City on a blunt trauma victim when we're 5 minutes away from the hospital. It doesn't take a rocket scientist or a study to come to the conclusion that that is a bad idea, however, if you can demonstrate some studies that elucidate that an advanced level of medical ALS care (of the kind supported in this article) is detrimental to patients, I would be interested. Surely with various EMS systems utilizing new technology and treatments, there will be such forthcoming. I was part of a REACT study which studied the effects of Lovenox vs. Heparin given concomittantly with TNKase in the prehospital setting. I personally had the chance to use the drug only once. The patient was a candidate and was being transferred from an outlying hospital. Enroute the medication was given without delay in transport. The patient had no visible or EKG response, beneficial or detrimental, to either medication. These studies are important to the evolution of EMS in a way that will determine whether in fact these procedures have a statiscally significant increase or decrease in patient mortality. However, due to the fact that no EMS systems are currently placing central lines, or doing many of the other things listed, means that no studies have been done. Therefore, it seems that to haughtily rule out the possiblity of such a role in EMS, seems a little hasty and without evidentiary merit.
Besides, according to the article, the priority component of the advanced practice paramedic role is not one primarily of procedural skills, but of a more broad didactic knowledge base which would allow one to make more of a practioner level decision vs. a technical one. (i.e. - referals, appropriateness of on-scene medical care without transport and evaluation, etc.)

 

[oudoc08]

12R34Y & oudoc08,
It's interesting that the majority of studies comparing BLS and ALS pertain to trauma or cardiac arrest. Consider that every single study 12R34Y cites pertains to trauma. I think this just reflects the greater focus of such studies. Yet, as oudoc08 alludes to, it's really the medical (NOT trauma) emergencies where ALS skills will make a difference. D50 to a diabetic... naloxone to a narcotics OD with depressed respirations... epi/diphenhydramine/methylprednisolone for anaphylaxis... CPAP/BIPAP for CHF... etc.

As for the advanced practice paramedic...I'm not sure about it. I support the reasoning behind it--that such a provider can be useful in certain domains. BUT, I don't think it should fall under the same auspices as other emergency providers. I'm not convinced that many of those skills are EMERGENCY (as in life or death skills). Why should such a provider be grouped with other emergency providers? We may as well start trying to bring in PAs into the fold and try to make them take a National Registry test...

My sentiments exactly. I somewhat agree with you on the point of trying to expand the scope of "emergency" providers to "non-emergency" situations. However, we have done this for years, if you think about it. Most EMS services routinely do non-emergency transfers. Some of these are critical care interfacility transports, some are returns to the nursing home. If we wanted to stick to our label, then we shouldn't be doing those. But, we do. Because it's part of good overall patient care. Similarly, the "emergency medical TECHNICIAN", is not a grounding factor, either. Paramedics for years, have been critically thinking and devising new strategies and implements for patient care, whereas the term TECHNICIAN usually implies, "if problem A, then answer B", etc. Sure we have protocols as general go-toward guidelines, but outside of 1% of your patients, how many patients are actually textbook and are treated exactly by protocol? Answer: Very very few. Why? Because we're treating people, not computers. Therefore, I would moreover argue that the advance practice paramedic, (and paramedic as well), lobby to have their designation changed from EMT-Paramedic, to paramedic or APP. I believe the "EMT" prefix is antiquated and no longer an accurate description of what the job entails. Perhaps back in the day, when paramedics were calling in to ask to start an IV on a code, but no more.

 

[Febrifuge]

As for the advanced practice paramedic...I'm not sure about it. I support the reasoning behind it--that such a provider can be useful in certain domains. BUT, I don't think it should fall under the same auspices as other emergency providers. I'm not convinced that many of those skills are EMERGENCY (as in life or death skills). Why should such a provider be grouped with other emergency providers? We may as well start trying to bring in PAs into the fold and try to make them take a National Registry test...

Agreed. And that's basically what I told the NAEMT in my comments on the report. While I appreciate the benefits for EMS in recognizing the skill level and dedication of experienced Paramedics, I think it's more a political gain than a level-of-care one. I'm also worried about who pays the salaries and the malpractice that would surely be needed for uber-Medics who would do all these various invasive, quasi-sterile procedures. Heck, bring PAs in to the EMS fold, or provide a means for Medics to advance to EMS PA status. Give 'em tools and more money. But just because we can do more in the field doesn't mean the field is the place -- and in those cases where it is, we should absolutely bring more hospital into our prehospital. But putting the burden on Medics seems like a step back to me, not a step forward.

 

[Febrifuge]

...I would moreover argue that the advance practice paramedic, (and paramedic as well), lobby to have their designation changed from EMT-Paramedic, to paramedic or APP. I believe the "EMT" prefix is antiquated and no longer an accurate description of what the job entails. Perhaps back in the day, when paramedics were calling in to ask to start an IV on a code, but no more.

This is a really good point, that practice has changed over time, and the way we label and think about things needs to change, too.

But I guess what I'm saying is, I don't see the need or the benefit in stepping so far away from the 'EMT' core of the skills and the job duties. I didn't like the study's suggestion that 'First Responders' should be given 40 hours of training and brought in to the 'EM-' family with 'EM-R' as a designation, and I don't think the patients (or the really talented, skilled, truly practitioner-level EMT-Ps) would benefit as much from creating APP designation as they would from being given scholarship money to get PA-C training. I felt it went a little too far on both ends.

I think there's already a job level and a skill set that goes with all the things the report lists, and I think it's badly needed. I also think it's PA.

 

[bennyhanna]

As an emt for several years now, I've noticed that not all advanced skilles are used frequently.

I'm left to say, Are you Kidding Me?

This is not a bunch of pre-med paramedics with a god-complex trying to impose their hate on poor defenseless paramedics (whose level 'advanced paramedic' doesn't even exist). I hope it doesn't exsist!

Unless these "Advanced Practice Paramedics" happen also to have the initials M.D. after their name, then the last thin I want is a medic starting a central line.

I would venture to guess that there must be several EMTs and Parameics on the NAEMT (go figure). It is easy to get the EMT attitude of 'I'm a doctor', but to let this seep into the curriculum is appaling.

Personally, I think all levels of EMTs in the U.S. are under-educated. 6 months to become a basic... 6-12 month to become a paramedic... and you want to be a doctor? It should be more like britian and austrialia... 4 years minimum for your EMT degree....

So... NAEMT medics... If you want so bad to further your skills and truly to be doctor-like.... then go to college, work your buns off, apply to med school, and hope you get in.

I seriously doubt any physician in his or her right mind would have anything to do with this.

Is this a cop out by those on NAEMT who wish they were doctors? If you want to do the cool stuff that doctors do, become a doctor.

Frustrating. I'd be darned before I'd let a medic start a central line or try to perform transvenous pacing on me or my family....

aaaGGGHHHHHH. Hello. My name is bob. I'll be your emt floating a transvenous line today. What's that? Oh, no, I am not a Pa or NP. No, I cannot prescribe. Yes, they do have 2 plus years of education on me. why can't they do these skills? Why don't I have a Masters? Isn't this a doctor's skill? Not anymore thanks to NAEMt.... OOps, missed on your central line... here, let me go ahead and suture that for you.... maybe I'll just crack your chest and perform cardiac surgery while I'm at it. after all, I am an emt.

 

[oudoc08]

As an emt for several years now, I've noticed that not all advanced skilles are used frequently.

I'm left to say, Are you Kidding Me?

This is not a bunch of pre-med paramedics with a god-complex trying to impose their hate on poor defenseless paramedics (whose level 'advanced paramedic' doesn't even exist). I hope it doesn't exsist!

Unless these "Advanced Practice Paramedics" happen also to have the initials M.D. after their name, then the last thin I want is a medic starting a central line.

I would venture to guess that there must be several EMTs and Parameics on the NAEMT (go figure). It is easy to get the EMT attitude of 'I'm a doctor', but to let this seep into the curriculum is appaling.

Personally, I think all levels of EMTs in the U.S. are under-educated. 6 months to become a basic... 6-12 month to become a paramedic... and you want to be a doctor? It should be more like britian and austrialia... 4 years minimum for your EMT degree....

So... NAEMT medics... If you want so bad to further your skills and truly to be doctor-like.... then go to college, work your buns off, apply to med school, and hope you get in.

I seriously doubt any physician in his or her right mind would have anything to do with this.

Is this a cop out by those on NAEMT who wish they were doctors? If you want to do the cool stuff that doctors do, become a doctor.

Frustrating. I'd be darned before I'd let a medic start a central line or try to perform transvenous pacing on me or my family....

aaaGGGHHHHHH. Hello. My name is bob. I'll be your emt floating a transvenous line today. What's that? Oh, no, I am not a Pa or NP. No, I cannot prescribe. Yes, they do have 2 plus years of education on me. why can't they do these skills? Why don't I have a Masters? Isn't this a doctor's skill? Not anymore thanks to NAEMt.... OOps, missed on your central line... here, let me go ahead and suture that for you.... maybe I'll just crack your chest and perform cardiac surgery while I'm at it. after all, I am an emt.

4 years to become an EMT? Are you kidding me. For 6 bucks an hour? Paramedic maybe. I left my last job making around sixteen an hour, which I didn't consider too bad considering I had a two year course paramedic course. That said, nobody is advocating grandfathering advanced skills to medics w/ my level of training. The article stated that the APP would be a minimum bachelors program. I would say triple the clinical hours, add an undergrad gross anatomy course, and alot of PBL style learning, as well as EMS management courses. Why not go to med school or PA school? Well, neither of those are trained to provide prehospital emergency medical care, so either they would have to do an ER residency, or maintain their paramedic license. That done, how many of those want to spend that amount of time and effort to go back to what they were doing prior, only this time with a few more skills that they can perform? None. Therefore, it is my opinion, that to have an advanced level prehospital provider, the only realistic way to do so, is to train extensively in the forum in which they started. (i.e. EMS). The major hold-up I see for a widely implemented program such as APP is demand. While they may have a nitch in rural areas, those are also the areas in which funding may not be available, and training may be severely lacking. So is there a solution? Is this a feasible option? I don't know. Honestly probably not. Peole gripe about the current cost of ambulance treatment and transport. Even if we put PA's or MD's in the back of an ambulance, most patients typically still regard ambulances as a way to get supervised transportation to the hospital to get "real" care. To drop five hundred bucks in the ER for "emergent" evaluation of toenail fungus, brings up little admonition, but when they get the same from the EMS company for treating their cardiac chest pain, they gripe. To put a higher trained provider in the back of ambulances routinely would perhaps get reimbursement from insurance companies, but private pay would have a real problem. Then we would run into the problem of more chest pain patients hopping into cabs to save money.
All in all, the idea of filling whatever need and nitch there is out there is ideal, and if there is a practical and economically feasible way to do it, in a way which puts safety and concern for patients at the forefront, then I'm all for it, but I'm willing to understand that that isn't always the case.

 

[12R34Y]

I still am holding onto my opinion. I think it is absolutely ridiculous to think that a APP could be starting central lines in the field. Why don't you think they couldn't be started in somebody's living room. that's the field isn't it? living rooms, garages, gravel roads, highways? I'm not quite sure that bouncing down the highway is conducive to starting a central line. My guess probably contraindicated.

where will these procedures like floating transvenous pacers be done?

OUDOC you made a good point. Rural areas that might possibly in a million years need something like this in NO WAY afford this. The two volunteers on the ambulance in the barn probably aren't going to convince their county seat to foot the bill for the stock of transvenous pacers, central line kits, sterile gowns/gloves etc.....

Again, in the rural areas in which you say they would be most useful the procedures they are talking about performing may only be performed once every 10 years in many rural areas. I mean........I worked in a busy system full-time for 5 years and I didn't even cric anyone?

Let's say that the rural ambulance company decided to foot the bill for ridiculous equipment that would never get used before expiring.........You've got to have at least 3-5 APP's working to cover the clock year round and that is assuming you don't give them any vacation.

So, these poor souls go to 4 years of schooling and work in Western wyoming running 500 calls/year and never doing any advanced skills. I can see them flocking to that job opportunity. I'm sure they'd be paid well.

APP already exists! It is called a PA.

later

 

[oudoc08]

APP already exists! It is called a PA.

later

PA's are no more emergency trained than an MD straight out of medical school. I'm not sure why you keep referencing them as master paramedics.

Ok, so I think we're beginning to agree to disagree. You don't think there is a role for APP, period. I do, but don't think it's economically feasible. I do believe there is room for expansion of the current paramedic curriculum, in terms not so much of advanced procedure (I think that's the easy part), but in the realm of greater didactic education. It's the only way to keep the field on par.

 

[12R34Y]

I can agree with almost everything you said in your last post.

It's not economically feasible more than likely.

I'm always for advancing didactics in EMS education. I plan on being hugely involved as an EM physician.

I agree that there is little need for advanced procedures per say.

I'm not saying PA 's are paramedics. I'm saying that the kind of didactic time spent to learn and know when to do some of the advanced procedures is very similar to a PA's level of care.

agree to disagree (kind of).

i'm out of this one. been very interesting.

good luck in your career.

later

 

[emtp2pac]

as someone who is both an emt-p and an em pa I think I can add a few things to this discussion.
1. many em pa's were previously paramedics or er nurses so they retain that knowledge
2. some places( parts of colorado only at this point) already use pa's on ambulances doing the scope described as APP for critical care transport services. they are all former medics who went on to pa school
3. some medics already start central lines in the field. the king county, washington state medic one guys all learn how to do subclavians for trauma. do I think this is overkill given that peripheral lines, io's and ej's aren't that tough? yup.
4. most companies that staff a medical provider in distant settings( oil rig, etc) already use pa's. I have several friends who do this in alaska and remote rural and/or island settings.
5. a pa right out of school without ems background is less skilled at running a code or trauma than a medic. one 6 week rotation in em plus acls and pals does not make you an em stud. however, as stated in #1 above, the vast majority of pa's who go into em already have significant em experience.

I am in favor of limited increase in scope for medics but as febrifuge stated above if you are going to do 2 more years of school after medic school it only makes sense to be a pa. pa's are licensed and accepted in all 50 states and have rx rights in 48 states. there will be 80, 000 licensed pa's by 2010. there is not currently a need for app's. app training would in essence be pa school at a similar cost and would not save money for distant, rural communities who likely have pa's working in them already. now as to the question of should pa's run on ambulances I think the answer is yes, but in the following way: each shift could have one or 2 rigs that are emt-p/emt-p/pa(dual cert) that would not respond directly to 911 calls but would be held in reserve for pts who clearly need a fast track level of service only. for instance all the folks who call 911 for minor lacs, ingrown toenails, rx refills, etc.the initial 911 unit on scene would call for the pa unit to come to the scene and then free themselves up for true 911 emergencies. keeping these folks out of the er's would decrease wait times in er's and allow genuinely sick folks to be seen more rapidly.

 

[Febrifuge]

That version of the future is a beautiful thing. Fewer ingrown toenails in the ED... advanced practitioners working in EMS, getting credit for their experience and training... I'm sorry, I think I have something in my eye...

 

[oudoc08]

as someone who is both an emt-p and an em pa I think I can add a few things to this discussion.
1. many em pa's were previously paramedics or er nurses so they retain that knowledge
2. some places( parts of colorado only at this point) already use pa's on ambulances doing the scope described as APP for critical care transport services. they are all former medics who went on to pa school
3. some medics already start central lines in the field. the king county, washington state medic one guys all learn how to do subclavians for trauma. do I think this is overkill given that peripheral lines, io's and ej's aren't that tough? yup.
4. most companies that staff a medical provider in distant settings( oil rig, etc) already use pa's. I have several friends who do this in alaska and remote rural and/or island settings.
5. a pa right out of school without ems background is less skilled at running a code or trauma than a medic. one 6 week rotation in em plus acls and pals does not make you an em stud. however, as stated in #1 above, the vast majority of pa's who go into em already have significant em experience.

I am in favor of limited increase in scope for medics but as febrifuge stated above if you are going to do 2 more years of school after medic school it only makes sense to be a pa. pa's are licensed and accepted in all 50 states and have rx rights in 48 states. there will be 80, 000 licensed pa's by 2010. there is not currently a need for app's. app training would in essence be pa school at a similar cost and would not save money for distant, rural communities who likely have pa's working in them already. now as to the question of should pa's run on ambulances I think the answer is yes, but in the following way: each shift could have one or 2 rigs that are emt-p/emt-p/pa(dual cert) that would not respond directly to 911 calls but would be held in reserve for pts who clearly need a fast track level of service only. for instance all the folks who call 911 for minor lacs, ingrown toenails, rx refills, etc.the initial 911 unit on scene would call for the pa unit to come to the scene and then free themselves up for true 911 emergencies. keeping these folks out of the er's would decrease wait times in er's and allow genuinely sick folks to be seen more rapidly.

Great post. Only thing I would like to clarify, is that you said that many PA's were EMT-P's originally. My point earlier was that a PA is not a master paramedic, and there was some references earlier that being a PA somehow was a subsitution for APP. I understand that many PA's were medics, but without an official post-PA training program (similar to an EM residency for MD/DO), it seems a liability to place PA's in a position to provide that type of care simply based upon being a paramedic in the past. Perhaps if one maintained and still was registered as a paramedic, but just to have been a medic once upon a time, seems practically, but not legally intellgent. Maybe I'm mistaken, as you don't have to be an EM-trained physician to work in an ER, but it seems like their actions are more likely to be called into legal question, based upon that lack of training. (BTW, I don't agree with non-EM trained physicians working in ER's either, but I understand the shortage of ER docs in that capacity). Something about a FP cracking a chest just gives me chills.

 

[deleted6669]

ou and emtp2pac- I think you are saying the same thing. I agree that just being a pa does not make you a master paramedic. In my version of pa field usage the pa's would have to also be current medics and would not respond directly to 911 calls but would be held in reserve for low acuity/fast track type pts who would likely see a pa in the er anyway if they were transported. the original medic unit on scene would determine based on some criteria who these pts were. then once they had summoned the pa unit they could be available again for real 911/emergent calls. I think the ideal mix would be to use a pa already working in an emergency dept and have them stay on the hospital payroll.an empa group could rotate between field shifts and work in the er. the medic would be paid by the ems agency. the scope of practice of the empa would be basically what they do all day long anyway and they would not need new supervising md's because they are already supervised by er docs. it would only take a minor change in the practice description form to include the field setting.

 

[bemused]

12R34Y & oudoc08,
It's interesting that the majority of studies comparing BLS and ALS pertain to trauma or cardiac arrest. Consider that every single study 12R34Y cites pertains to trauma. I think this just reflects the greater focus of such studies. Yet, as oudoc08 alludes to, it's really the medical (NOT trauma) emergencies where ALS skills will make a difference.

Has anyone seen the OPALS studies out of Canada, looking at medical outcomes moreso than trauma? Not much published yet, but I hear they have something large coming out in NEJM soon. From their site -

OPALS Abstracts 2003
1. What is the Impact of Advanced Life Support on Out-of-Hospital Cardiac Arrest?
2. Multi-center Controlled Clinical Trial to Evaluate the Impact of Advanced Life Support on Out-of-Hospital Chest Pain Patients
3. A Location-Specific Utility Measure to Guide the Distribution of Public Access Defibrillation (PAD) Programs within the Community
4. Determination of Accurate Out-of-Hospital Cardiac Arrest Location in 20 Communities
5. Quality of Life Outcomes for Respiratory Distress Patients
6. Predictors of Survival for Out-of-Hospital Respiratory Distress Patients in the OPALS Study
7. Multi-center Comparison of GCS and RTS Scores at Scene Versus at Trauma Hospital
8. How are Pediatric Patients Managed by EMS and What are Their Outcomes?
9. Multi-center Comparison of the Predictive Value of the Revised Trauma Score and the Glasgow Coma Scale
10. Mathematical Model Predicting the Potential Impact of Various Community Bystander CPR Rates on Overall Survival from Cardiac Arrest.
11. Outcomes of Patients with Non-Traumatic Pre-hospital Hypotension

Here's the direct link - OPALS 2003 Abstracts

I'm quite interested to hear everyone's responses!

As for the scope of practice issue, there are already some paramedics with an advanced practice --> Paramedics are allowed to perform cricothyroidotomy in 68 programs (85%), pericardiocentesis in 24 (30%), and tube thoracostomy in 23 (29%). At least that's beyond what we did on our streets. Maybe in that particular setting it is appropriate.

Give 'em tools and more money. But just because we can do more in the field doesn't mean the field is the place -- and in those cases where it is, we should absolutely bring more hospital into our prehospital.

Yeah! What he said!

 

[12R34Y]

I was under the impression that most paramedic programs did cricothryoidotomies. Is this not true?

the three services I've worked for in 2 different states all did it. I just assumed it was standard of care.

later

 

[bemused]

I was under the impression that most paramedic programs did cricothryoidotomies. Is this not true?

the three services I've worked for in 2 different states all did it. I just assumed it was standard of care.

later

I've worked in 2 agencies in two states - one did surgicals and the other did needles, both after calling and getting the go-ahead from medical control. Never worked anywhere that we did pericardiocentesis or tubes, though (main point, sorry if that wasn't clear).

 

[deleted6669]

lots of places do rapid sequence intubation and a few do field tpa already as well. it looks like the scope of practice authors didn't even survey what the range of CURRENT practice is......

 

[12R34Y]

you had to call med control for airway? wow. too bad for the patient.

that's like calling for defibrillation. kind of important to not fiddle around.

wonder what the rationale behind having you guys call med control was?

Having the physician on the other end say things like..."are you sure you can't intubate them or bag them?"


later

 

[oudoc08]

you had to call med control for airway? wow. too bad for the patient.

that's like calling for defibrillation. kind of important to not fiddle around.

wonder what the rationale behind having you guys call med control was?

Having the physician on the other end say things like..."are you sure you can't intubate them or bag them?"


later

We had RSI, and surg. airways at the last place I worked. We had to get orders for RSI, and for cric. of partially obstructed airway, but not for total or criical obstruction. It used to be that the most time critical procedures such as unstable cardioversion of an unconsicious VT w/ a pulse, were med control only, but the crap that could wait awhile was not. After someone dislodged their head from their ass, this got changed. Now, anything that can't wait is medic discretion, as it should be, anyways. I mean, after all, let's just assume that you have a patient whose airway becomes obstructed totally during your care (say epiglottitis), and you call for orders to cric. What are you going to do if the ER doc says no? Are you going to sit there and watch the patient suffocate? Hopefully, you'd cric them anyways, and suffer the consequences later. Otherwise, you're a piece of pond scum. But, obviously, no physician in their legal right mind, would turn down an urgent request to gain a surgical airway in this case, so if they're going to approve the request 100% of the time anyway, why even have the medic have to call? Especially, when it's costing the patient valuable time. This was the logical rational for changing the protocol, and I highly encourage any services still requiring medical control consult for urgent procedures, to make it your goal to get that changed. It's not hard, usually a little common sense is all it takes.