Future Paramedic Scope?

[46Young]

There has been much discussion about increased education leading to increased scope of practice. Given the current state of medical technology and advancements, how advanced do feel the paramedic scope should/could be? How much autonomy? Please differentiate from 911 and IFT.

We obviously can't make a definitive Dx or create our own protocols, as only an MD can do that, and we can practice only when under the OMD's license. We also don't have the space for labs, portable CT or x-rays on the rig. So, how far do you think the paramedic profession can go if education is in line?

There's probably a thread or two in regards, but I don't feel like looking them up.

 

[TransportJockey]

There has been much discussion about increased education leading to increased scope of practice. Given the current state of medical technology and advancements, how advanced do feel the paramedic scope should/could be? How much autonomy? Please differentiate from 911 and IFT.

We obviously can't make a definitive Dx or create our own protocols, as only an MD can do that, and we can practice only when under the OMD's license. We also don't have the space for labs, portable CT or x-rays on the rig. So, how far do you think the paramedic profession can go if education is in line?

There's probably a thread or two in regards, but I don't feel like looking them up.

Why differentiate between 911 and IFT? If you want to do that, I can see the scope for IFT medics expanding while the 911 is find where it's at.

 

[Shishkabob]

I truthfully see more emergency surgical operations being able to be performed in the field in the future, at least in the more progressive of areas.

 

[TransportJockey]

I truthfully see more emergency surgical operations being able to be performed in the field in the future, at least in the more progressive of areas.

Are you talking like C-Section or something else? A couple examples would be good

 

[Shishkabob]

Sure, c-section, emergency amputation like at a scene where you don't have time for a doctor, more places doing episiotomies, among other things.

Of course, mainly for the more rural of agencies.

 

[Bloom-IUEMT]

Sure, c-section, emergency amputation like at a scene where you don't have time for a doctor,

Jesus I hope not! Really...how often are these needed besides on tv?


In the UK they have Emergency Care Practitioners that have equivalent to Bachelor's or Master's degrees. These health care providers can do simple medical procedures like suturing and can even prescribe medications. I think if we really want to reign in healthcare spending this would be an integral step.

 

[VentMedic]

I truthfully see more emergency surgical operations being able to be performed in the field in the future, at least in the more progressive of areas.

How about concentrating on some basic pharmacology? Many ALS trucks don't carry enough meds to keep an 80 y/o 40 Kg person comfortable. Do you realize the gap there is between the typical ALS truck drug box and that of a good Flight, Specialty or CCT team. Some of these Paramedic teams can set up their own drips and even titrate them without an RN's presence. How about ventilators more complex than an ATV? Do you know how many ALS trucks still do not do even the simplest form of CPAP? 12-Lead EKG? Do you realize how many ALS trucks in this country still don't do this? Do you know how many that do just rely on machine interpretation? How about the ability to access common venous indwelling devices?
How about airway proficiency?

Then, for IFT there is the IABP, VADs, critical care patients and maybe even get actual critical care experience as the Paramedics in other countries receive.

The U.S. Paramedic has a long way to go to just master some of the basic ALS skills and education before it can move on. Remember this profession is starting from a Paramedic that has an average of 600 - 1200 hours TOTAL of training. That is the equivalent of a "BLS" provider in other countries. To get to even a 2 year degree is a huge step for some in the U.S.

 

[Shishkabob]

How often is a surgical airway needed? Just because they aren't common doesn't make them any less life-saving in the situations they would be used for.


Note, I did NOT say it should be solely left to us as to when to use them, and that they would almost always be a last resort. All I said is I see it happening.

 

[Bloom-IUEMT]

How often is a surgical airway needed? Just because they aren't common doesn't make them any less life-saving in the situations they would be used for.


Note, I did NOT say it should be solely left to us as to when to use them, and that they would almost always be a last resort. All I said is I see it happening.

Touche. I'd be willing to bet the need for an emergency field c-section much less commonly indicated than a surgical airway which is needed in about 6 in every 1,000 trauma patients. And although its a somewhat safer and more common surgery than many other surgeries it's still pretty major. It involves at the least a regional epi or subdural anasthetic. I imagine IMHO that the only time it could be used is when the patient is non-resusable and the baby is at term. But think about your wife, girlfriend, daughter getting surgery from someone with a degree from the local community college. If anyone is going to touch my wife with a scalpel s/he better be an MD.
But if you think about all the crap you'd have to learn just to perform that exceedingly rare surgery it seems as though that time would be better spent learning other skills you would use. Like I would LOVE to see Paramedics do suturing and prescribe meds (with the requisite education of course).

 

[46Young]

Why differentiate between 911 and IFT? If you want to do that, I can see the scope for IFT medics expanding while the 911 is find where it's at.

IFT and 911 are two different beasts. IFT has the benefit of an MD's definitive Dx, as well at labs, various diagnostic tools, etc. Perhaps the properly educated medic would be able to titrate/initiate/DC certain drips if needed, or have protocols to change vent settings (way over my head, just thinking out loud, please don't bite) if needed, based on prior labs/Dx/diagnostics.

See Vent's post above, most 911 agencies carry only about 30 meds or so, and have pain management protocols well below what's needed for the pt. Due to poor education, particularly lack of pharmacology and A&P, a good number of medics are ill prepared to manage any untoward reactions from these few meds, let alone the vast array (for our field) they may come across in the IFT setting. Many medics don't even know what a typical loading dose of heparin is for the MI pt going to the lab, for example, or at what range a typical tridil drip may run at. Or why the RSI meds are given in the order that they are. Or how to manage a vented sedated pt on propofol who has become hypotensive. Any decent medic should be able to answer these questions without delay, at least those in IFT.

Heck, some don't even realize that NTG 0.4 mg SL is actually very high dose nitro, and don't know that drip versions even exist.

 

[46Young]

I think that further advancements on the 911 side would be based on the strategy of doing more for the pt in terms of stabilization prior to txp. However, we'll always be limited by the lack of diagnostic tools such as a CT scan, or labs. They would take too much time onscene to be of any benefit, if we actually had access to one, hypothetically speaking.

On the IFT side, we would have greater lattitude in managing/initiating different drips/boluses and different machines without necessary OLMC consult. The thing is, the receiving facility will typically require you to advise of any changes in pt status anyway, and the receiving MD will want you to do what THEY want. Understandable.

 

[VentMedic]

IFT and 911 are two different beasts. IFT has the benefit of an MD's definitive Dx, as well at labs, various diagnostic tools, etc. Perhaps the properly educated medic would be able to titrate/initiate/DC certain drips if needed, or have protocols to change vent settings (way over my head, just thinking out loud, please don't bite) if needed, based on prior labs/Dx/diagnostics.

I am not biting but if you want to be successful and work for a progressive Flight, Specialty or CCT team, you had better know labs and meds. Often we do initate meds and ventilation upon our arrival. An ED doctor may be reluctant to sedate, intubate and ventilate a TBI initially but we may need to for flight. A chest tube may be needed. Arterial line to go with the pressors. Blood products.

I posted these scenarios awhile ago to give examples of what a decent CCT should be looking at.

http://www.emtlife.com/showthread.php?t=8948&highlight=flight+scenarios

http://www.emtlife.com/showthread.php?t=13694&highlight=flight

Unfortunately, many "CCEMT-Ps" just arrive, match the numbers on the IV pumps and ventilator and run L&S real fast to the other hospital. And yes, I have known many ICU and ED physicians that have refused to place their patients on these trucks unless hospital staff accompanied.

 

[VentMedic]

There is one little snag in the future of advancing the Paramedic: qualified educators.

Some of the Paramedic instructors teaching now are barely qualified to teach an EMT class. Very few have degrees of any type. And, it is possible to graduate from a 3 month wonder mill and be offered a teaching position with the same medic mill before the ink is dry on your cert.

 

[rescue99]

There is one little snag in the future of advancing the Paramedic: qualified educators.

Some of the Paramedic instructors teaching now are barely qualified to teach an EMT class. Very few have degrees of any type. And, it is possible to graduate from a 3 month wonder mill and be offered a teaching position with the same medic mill before the ink is dry on your cert.

Not all instructors are bad just like not all english professors are bad...just a lion's share! There are no better educators in the college setting than in the "mill" programs. It hasn't mattered one single bit. Ethics, standards, values, respect, repsonsibility and experience. These are what make a good program and they start with the man (or woman) at the top. It isn't all about the ink.

 

[VentMedic]

Not all instructors are bad just like not all english professors are bad...just a lion's share! There are no better educators in the college setting than in the "mill" programs. It hasn't mattered one single bit. Ethics, standards, values, respect, repsonsibility and experience. These are what make a good program and they start with the man (or woman) at the top. It isn't all about the ink.

Don't take it so personally. Again, we must always defend the least common denominator. Okay so Bubba at the medic mill is a real nice guy and can talk endlessly about his heroic feats. However, that does not necessarily qualify him to teach. Yet, since there may not be other examples to compare him with, he gets teacher of the year.

In the world of education, it is common for the educator to have at the very least the same degree they are teaching. Most colleges require at least one higher and the better institutions require a graduate degree.

Yes it does start at the top which is why the educator needs to be targeted and not who the Fire Chief plays golf with.

 

[46Young]

I am not biting but if you want to be successful and work for a progressive Flight, Specialty or CCT team, you had better know labs and meds. Often we do initate meds and ventilation upon our arrival. An ED doctor may be reluctant to sedate, intubate and ventilate a TBI initially but we may need to for flight. A chest tube may be needed. Arterial line to go with the pressors. Blood products.

I posted these scenarios awhile ago to give examples of what a decent CCT should be looking at.

http://www.emtlife.com/showthread.php?t=8948&highlight=flight+scenarios

http://www.emtlife.com/showthread.php?t=13694&highlight=flight

Unfortunately, many "CCEMT-Ps" just arrive, match the numbers on the IV pumps and ventilator and run L&S real fast to the other hospital. And yes, I have known many ICU and ED physicians that have refused to place their patients on these trucks unless hospital staff accompanied.

No, I was just referring to having the ability to change vent settings. That's way over my head. It would be negligent for the IFT medic to not have a basic understanding of lab values and their significance, especially at the CCT level. I am ignorant to the additional training/edu. for the flight medic, let alone a flight RN. I would like to do flight at some point in the future, though, when I'm ready.

 

[Ridryder911]

Not all instructors are bad just like not all english professors are bad...just a lion's share! There are no better educators in the college setting than in the "mill" programs. It hasn't mattered one single bit. Ethics, standards, values, respect, repsonsibility and experience. These are what make a good program and they start with the man (or woman) at the top. It isn't all about the ink.

Somewhat true, but at least they are educated and NOT trained. Anyone that does not know the differential does not know anything about education.

Ironically, we understand that those to present any education and training to our youth it is important for them to be formally educated as in requiring teachers to have the least of a baccalaureate degree to teach even kindergarten. Unfortunately, we fail to see the same need in teaching complex philosophy, didactics and procedures of intubation, performing crich's, ECG interpretation and so forth for EMS personnel. A kindergarten teacher requires the minimum of a 4 year degree and meanwhile the Paramedic Instructor (not educator) only requires a GED in the majority of the U.S. states. Do we not see something wrong with this?

We need to look at other medical professionals; as I use that term loosely as the definition of professional itself would require at the least academic setting. Even to teach and instruct LPN/LVN requires the minimum of a BS degree and most states requires graduate level. Even for RN the majority require graduate to post-graduate, doctoral level, yet we want to proclaim professionalism? Kinda hard to do when those that teach cannot acclaim that level in the world of academia.

There is much difference between training and educating. This is where my focus in to attempt to standardize those that teach to be accountable. Other than taking a 39 hour instructor course and being blessed as an instructor because you were thought as being a good medic during your career.

Actually, I do debate your analysis and wonder if you have any basis on describing those that teach in academic setting versus "medic mills'; as I can cite researched other findings. It is a well known documented fact that the higher the education the teacher has the higher percentage of pass rates in according to boards and certifications. Even NREMT describes that the higher educated the person teaching the higher the written pass rate and associated skill rate pass. Yes, that matters as if one cannot pass such examination(s) one cannot be employed, but more how well is that person prepared for the job market and performance of providing care?

Personally, I would wish each state would require minimum standards of those that teach EMS programs have the minimum educational standards alike any other teacher. Obviously what we are doing is NOT working. We still teach out of textbook(s) that are written at a junior high level reading level, and national test are written at upper elementary and mid high level high school level and still only have a 65% first time pass rate, the system is broken.

Place some credibility into EMS programs. Yes, one can get an educated dumbass but yet again it is to replace such an individual as they will be held to some accountability and standards.

As a profession we will never achieve accountability or status as a professional until we have met the generalized standards of becoming one. Sorry, going to a vocational trade school where the same emphasis is place upon cake decorating and auto mechanics is not the same as academic science course level. We want to be recognized as a professional (as we should) such as pay, status; then we have to meet the same requirements as professionals do. Sorry, no short cuts should be allowed.... we have always tried that it simply does not work.

R/r 911

 

[Akulahawk]

I would imagine that a lot of us that have taken pre-requisite coursework for other healthcare fields prior to getting into Paramedic School probably have a MUCH better overall understanding of what is going on with patients encountered in the field. Back when I was far more active a Paramedic than I was, I (almost universally) surprised RN's that I contacted for report about the patient I was transporting... as I asked them to give report to me exactly as if they were giving report at shift change. Most did... and to their surprise, I'm sure, it was clear I understood the report.

Judging from their reactions, I was outside the norm for them.

Training should be how you acquire the skills... Education is how you acquire the knowledge how to appropriately use those skills. As a group, Paramedics need to be better educated going into a Program than they are now. As the overall educational level rises, we'll see increases in the scope of practice.

Given enough time and appropriate coursework and clinical experience, Paramedics can take over the role of a Critical Care Transport Provider... regardless of the length of transport.

And I agree that IFT and 911 work are two different beasts. I quite enjoyed doing IFT work because it's very much more challenging than doing 911. Most of the patients I got from the 911 system were relatively easy (even the ALS ones) to manage. The IFT patients on the other hand... They typically had multiple problems confounding and compounding their presentation and management.

 

[Melclin]

Training should be how you acquire the skills... Education is how you acquire the knowledge how to appropriately use those skills. As a group, Paramedics need to be better educated going into a Program than they are now.

This talk of Education Vs Training is all the rage here at the moment. To be honest it annoys me a little, because all the focus is on education and not training. I think we need a balance of both. Over your way, you obviously have a strong lack of education. This is certainly not our problem. I think we have overshot the mark and sacrificed a little to much practical training in favour of education.

Obviously I'm not advocating against education - that would be daft. But as you say Akula, they are different, they both provide students with different things, and, importantly, they are not mutually exclusive. It is important to have both, and in your quest to achieve better education, try not to make the same mistakes as we did earlier on of churning out over educated, under skilled medics (although it is perhaps important to note that our levels are different to yours. Our "medics" are more on par with your EMT-I, its our MICA medics that practice at the level you consider to be "medics" and that requires a trip to grad school for a year + some years under your belt practicing at the lower level, so it might be a moot point).


It's interesting that in all the conversations I read on this board about education, it always seems to be emphasizing pre-requisite education. Why is it that everybody here seems to want people to do separate a&p and pharm and so on before a paramedic degree. Why not include them all as part of the same program. Then you can make sure you know what you're getting, streamline it to have a clinical focus etc. Not criticizing so much as just wondering.

 

[VentMedic]

It's interesting that in all the conversations I read on this board about education, it always seems to be emphasizing pre-requisite education. Why is it that everybody here seems to want people to do separate a&p and pharm and so on before a paramedic degree. Why not include them all as part of the same program. Then you can make sure you know what you're getting, streamline it to have a clinical focus etc. Not criticizing so much as just wondering.

It is much easier to teach someone about paramedicine if they have some understanding of the body and what a medication is. The skimpy 20 - 30 hour overview classes "as it pertains to EMS" for each are not enough.

All the other allied health professions and nursing take the prerequisites and then go into their field specialization. You can not say "you only need to be concerned about just this piece of anatomy or just memorize this flashcard". One must know that systems function together and that medications also do more than just what is on a flashcard. U.S. EMS has taken each individual skill and perceived it as a separated entity. Thus there is a fragmentation. Instead of having enough knowledge to incorporate many different concepts, they learn bits and pieces only to wonder why they fail when it comes to advanced procedures like RSI.

I again refer to this hideous article which believes as a few others do that one should just know enough A&P or pharm to do a few skills as a Paramedic. Yes, U.S. EMS has "streamlined" its education to where some have become skill monkeys who can only do skills but don't know why they are doing them or when they shouldn't do them.

http://www.fd-doc.com/2000Hours.htm

BTW, lido numbs the heart and CPAP pushes lung water. That is all you need to know about these two things.