-ADVANCING PARAMEDIC's SCOPE OF PRACTICE-

[RanchoEMT]

What as a Paramedic were you(anyone) unable to provide to your patient's, especially those that died??? What additional skills/knowledge do you think needs to be added to a Paramedics Scope of Practice?

I asked this question in a previous post but didn't get an answer.... But I feel its a good question, So I ask it again. Has anyone ever had a patient expire because you as a healthcare provider couldn't perform a specific procedure or just didn't have the knowledge base for something that could have saved a patient's life??? Example: Field Thoracotomy, Additional Drugs, etc.

 

[medicRob]

 

[usalsfyre]

:unsure:
I have seen more cases of patients expiring because of too large of a scope of practice than too small of one.

What needs to be added? Primary care and real symptom (pain, agitation and nausea)management.

What needs to be taken away from all but a few specialized practitioners? Endotracheal intubation, anti-dysrhythmics, thrombolysis, percadrial centisis, thoracostomy....the list goes on and on.

 

[medicRob]

I have seen more cases of patients expiring because of too large of a scope of practice than too small of one.

Nailed it. EMS has a horrible tendency to overtreat. Sometimes, "benign neglect" as some medics call it is the best option.

 

[mycrofft]

"This is the song that never ends....."

There is a practical limit as to what you can do in the field, so there will always be a pt, no matter how rare, who just exceeds it....maybe. (Pareto Principle at work aka "eighty/twenty rule").

Sort of like Code Three response in cities; generally if seconds count, the pt's going to be dead anyway. "If only I could have done a MRI..." means there's lots wrong and any one or even two field measures will not work. Pt's die. That's it.

That said...why can't field people do fingerstick glucomtery? Silly.

 

[fast65]

Before we look at extending an already extensive scope of practice, we need to look at expanding the education to adequately cover the one we have now. A larger scope at this point in the game could only be more detrimental than helpful in my opinion.

 

[nwhitney]

That said...why can't field people do fingerstick glucomtery? Silly.

Serious? We learned this about 3 weeks ago in class. Unless I'm confusing fingerstick glucomtery with something else.

 

[VFlutter]

Serious? We learned this about 3 weeks ago in class. Unless I'm confusing fingerstick glucomtery with something else.

It is not an EMT-B NREMT recognized skill, depending on where you work some places allow it.

 

[medicsb]

Paramedics need to have:
- a basic understanding of psychology and abnormal psychology.
- a basic understanding of sociology.
- Proficiency with reading and writing in english. (Most read and speak fine, but many could use some lessons in grammar and punctuation).
- Basic understanding of epidemiology and medical statistics.
- Basic understanding of anatomy and physiology.
- Education on low acuity diseases and the appropriate level of care required to treat
- Education on low acuity presentation of severe disease (e.g. CHF, COPD, etc.) and its management.
- Education on substance abuse

With this sort of education, maybe paramedics could reliably refer patients to places other than hospitals, such as clinics, doctors offices, psychiatric hospitals, detox centers, etc.

As far as procedures, I think ultrasound will be the next big technology to move into EMS. (Yeah, yeah. I know some places already do it. But the overwhelming majority do not).

There might be a place for pericardialcentesis, but I think it should be studied to see if it would have any effect on M&M. Probably should only be performed when ultrasound is available for quick identification of effusion or tamponade. Oh and only by a small group medics - not for everyone (like ETI should be). (Again, yes, I know some systems do this, but they probably shouldn't.)

As far as for dying/dead patients, most paramedic have the tools to manage them, but not experience.

 

[nwhitney]

It is not an EMT-B NREMT recognized skill, depending on where you work some places allow it.

I know I'm always a little surprised when I hear of agencies or states not allowing it.

 

[VFlutter]

Paramedics need to have:
- a basic understanding of psychology and abnormal psychology.
- a basic understanding of sociology.
- Proficiency with reading and writing in english. (Most read and speak fine, but many could use some lessons in grammar and punctuation).
- Basic understanding of epidemiology and medical statistics.
- Basic understanding of anatomy and physiology.
- Education on low acuity diseases and the appropriate level of care required to treat
- Education on low acuity presentation of severe disease (e.g. CHF, COPD, etc.) and its management.
- Education on substance abuse

You basically just described the prerequisites for nursing school. I agree that it would be great if we could move towards that level of education for paramedics but the compensation will need to move up to that level as well. Until paramedics make the same as nurses, there will be no justification for requiring that level of education.

During my pre-nursing course work I got a minor in Psychology, I had to take abnormal psych and Drugs & Behavior. I think those should be required classes, I learned so much useful info in those two classes.

 

[usalsfyre]

You basically just described the prerequisites for nursing school. I agree that it would be great if we could move towards that level of education for paramedics but the compensation will need to move up to that level as well. Until paramedics make the same as nurses, there will be no justification for requiring that level of education.

Horse puckey. Until paramedics are educated at a level similar to nurses, their not going to get paid as much. Period. The "pay me more and I'll go back to school" argument doesn't work anywhere but in too many paramedics own heads.

The desire to change has to be internal, not external. Otherwise it's too easy to make excuses.

 

[MrBrown]

POC lactate and cardiac markers
Obtaining blood samples for culture
Antibiotics for sepsis. septic shock and meningoccal septicemia

Oh and lets throw in pre hospital plain films and CT too?

 

[the_negro_puppy]

POC lactate and cardiac markers
Obtaining blood samples for culture
Antibiotics for sepsis. septic shock and meningoccal septicemia

Oh and lets throw in pre hospital plain films and CT too?

We have Ceftriaxone for Meningoccal speticemia. Never seen or heard of anyone using it though ^_^

I would like to see some sort of anti-anxiey drug + muscle relaxant (Diazepam) added. Good of anxiety, agitated psych patients and spasmic muscle pain

 

[crazycajun]

Paramedics need to have:
- a basic understanding of psychology and abnormal psychology.
- a basic understanding of sociology.
- Proficiency with reading and writing in english. (Most read and speak fine, but many could use some lessons in grammar and punctuation).
- Basic understanding of epidemiology and medical statistics.
- Basic understanding of anatomy and physiology.
- Education on low acuity diseases and the appropriate level of care required to treat
- Education on low acuity presentation of severe disease (e.g. CHF, COPD, etc.) and its management.
- Education on substance abuse
As far as for dying/dead patients, most paramedic have the tools to manage them, but not experience.

Not sure about other areas but the following are the requirements For AAS in Emergency Medical (Paramedic) Degree.

Medical Terminology
Anatomy and Physiology I
English Composition I
College Algebra
English Composition II
Basic Anatomy & Physiology II
Microcomputer Applications
Elective (must be health services related)
Intermediate Emergency Care
Pharmacology
Intro to Electrocardiogram
EMS Field internship
SWE in Advanced EMS
Advanced Emer. Medical Care I
Advanced Clinical Experience I
Public Speaking
Advanced Emerg Med Care II
Advanced Clinical Experience
Advanced EMS Field Intern. II
General Psychology
Emergency Vehicle Operations
EMS Management Seminar
Humanities Elective

You must also be currently certified as an EMT-B or I. Not much difference from the ADN program here. Only a couple of classes. I just prefer to be on the truck.

 

[STXmedic]

We have Ceftriaxone for Meningoccal speticemia. Never seen or heard of anyone using it though ^_^

I would like to see some sort of anti-anxiey drug + muscle relaxant (Diazepam) added. Good of anxiety, agitated psych patients and spasmic muscle pain

I've never seen a system that didn't have Diazepam on board... (I'm sure they're out there, but very uncommon I'm sure)

 

[usalsfyre]

I've never seen a system that didn't have Diazepam on board... (I'm sure they're out there, but very uncommon I'm sure)

No diazepam here, only lorazepam and midazolam.

At one point DC didn't even have a benzodiazepine in the formulary.

 

[mycrofft]

No benzos?

Med Control likes ativan, but valium is less of a "yo-yo" drug (longer halflife).
OK, we extend paramedic's scope. Now what system will be used to deliver them? Bigger (yet) vehicles? HOw many? Helos? Or skip transport and stay with the pt until they're stable enough to be driven or drive themselves to their family MD on an appointment?
How would someplace like Cherry County, NE do this? I imagine interior Australia and rural New Zealand wold ahve trouble justifying something like that.

edit: I knew mentioning glucometry would get things going. Like bread on a duck pond...

 

[the_negro_puppy]

I've never seen a system that didn't have Diazepam on board... (I'm sure they're out there, but very uncommon I'm sure)

We carry Midazolam for seizures, other than that, no other benzos

 

[Smash]

We have Ceftriaxone for Meningoccal speticemia. Never seen or heard of anyone using it though ^_^

I would like to see some sort of anti-anxiey drug + muscle relaxant (Diazepam) added. Good of anxiety, agitated psych patients and spasmic muscle pain

That's because N. Meningitidis is a relatively uncommon beast where you are. In South Auckland or the Sub-Saharan meningitis belt on the other hand... I gave some to a 15 month old the other day by the way.

As for expanding the scope of paramedics, sure, we could do it, but the real question is should we do it. Identify a need first, then consider whether it is beneficial to expand to manage that need. It's not about having lots of toys, it's about using the toys you have in a careful, considered and evidence based manner to provide the best possible care for your patients.
To really expand scope, all we need to do is expand the education requirements to drive the big white bus.