National EMS Scope of Practice Model Revision

[EpiEMS]

Has anybody raised questions or comments to the NAEMSO with respect to the National EMS Scope of Practice Model revisions?

Anything you'd like to suggest? Here's the current version.

Naturally, EMR and EMT naloxone is something they're talking about. I'm thinking about mentioning:

Additions for EMRs:
- Tourniquets
- Nasal airways
- Assist with patient prescribed auto-injector for anaphylaxis

Additions for EMTs:
- Glucometry
- CPAP for EMT
- Field cervical spine clearance at the EMT level
- Epinephrine autoinjectors for anaphylaxis and severe asthma exacerbations

Additions for AEMTs:
- ETCO2 for AEMTs (if you're placing Esophageal-Tracheal Multi-Lumen Airways, shouldn't you be placing ETCO2?)

Not so sure about medics...

Removal/material alteration suggestions:

I think they should alter lines like: "The Emergency Medical Technician may make destination decisions in collaboration with medical oversight." to say "The Emergency Medical Technician may make destination decisions in collaboration with pre-established protocols and/or on-line medical oversight."

 

[VentMonkey]

Anything you'd like to suggest?

Yes, paramedics:

A more focused approach to a respiratory module, and perhaps basic ventilator management, or a properly, and appropriately suited introduction.

Otherwise, remove intubation altogether; we really need to stop fooling ourselves.

if you're placing Esophageal-Tracheal Multi-Lumen Airways, shouldn't you be placing ETCO2?

Yes, absolutely.

 

[hometownmedic5]

Sometimes I forget that there are place in this country more backwards than MA. Everything on that list with the exception of CPAP is already in our BLS scope and i consider them fundamentals. Envisioning a system where that's not the case cooks my noodle...

 

[NomadicMedic]

As they always say, if you've seen one EMS system, you've seen one EMS system.

As someone who's worked in multiple states, first as a basic, then as a medic, there is NOTHING the same about any of them, with the exception that they all call themselves EMS.

My suggestion is a TRUE national scope of practice for paramedics and to stop trying to patch up shaky systems with piecemeal certs.

It's should be EMT and PARAMEDIC. That's it.
EMT should double the length of the program and focus less on the lifesaving and more on the hand holding and customer service. An EVOC module should be mandatory.

Paramedic should be a mandatory 2 year program with much more focus on the patho and less on the hero. And yes, intubation should probably be pulled. None of us are competent.

 

[Carlos Danger]

I didn't realize this was up for review again. I'll have to review the old one and give it some thought.

@EpiEMS I think your suggestions are all good ones. @VentMonkey and @NomadicMedic, I personally probably wouldn't advocate removing intubation at this point. De-emphasize it for sure, and I don't think RSI should be a standard intervention, but I do think intubation is something that paramedics should get some exposure to and practice with during their initial training.

 

[hometownmedic5]

I agree. We either need to way increase initial training, coupled with mandatory recertification and performance requirements, or scrap it all together. What we have now is a crap shoot. Some providers are good at it just because they've done it a million times. Most of us are terrible(mainly due to lack of opportunities and minimal understanding).

I could live in world where all I had was an SGA.

 

[VentMonkey]

I personally probably wouldn't advocate removing intubation at this point. De-emphasize it for sure, and I don't think RSI should be a standard intervention, but I do think intubation is something that paramedics should get some exposure to and practice with during their initial training.

Remi, I'd love for you to elaborate, and I'm not being a smartarse here either.

How do we de-emphasize, yet still remain proficient? Do you think that's a reality? Should it only be left for certain (specialty certificate) providers?

Also, where--if at all--do you think RSI fits into prehospital medicine?

 

[SpecialK]

Additions for EMTs:
- Glucometry
- CPAP for EMT
- Field cervical spine clearance at the EMT level
- Epinephrine autoinjectors for anaphylaxis and severe asthma exacerbations

What about the following?

Entonox or methoxyflurane (I can't believe you guys don't have either of these!)
GTN
12 lead ECG acquisition
Salbutamol and ipratropium
IM midazolam for status epilepticus
IM adrenaline (from a syringe - why bother with a bloody autoinjector?)
IM and IN naloxone (you blokes probably use it a bunch)
IM glucagon (if you can take a BGL why can't you treat hypoglycaemia)
Oral ondansetron

We have some other things like tramadol, olanzapine and loratadine plus something else I am forgetting but they're not "big ticket" items. I would even say GTN is probably not that important ... no evidence it really does anything good anyway but doesn't seem to be going away any time soon!

 

[VentMonkey]

@SpecialK all great stuff. Only one small snag...'murrica.

 

[Jim37F]

I do wish I had something more than cold packs for pain......give me something more than that and something for nausea and those two alone would make me feel 99% more effective when the ALS squads here inevitably BLS any trauma that's not a Trauma Center activation or any other pain that isn't painful to them to look at lol vs the current method of "I know you're in abdominal pain and I can't do anything for it and even the hospital isn't giving any meds whilst letting you wait on my gurney in the hallway"........(we're more likely to get something like Entonox or methoxyflurane at the BLS level for pain management here than we are to change that culture.....)

 

[DesertMedic66]

If we are going to give EMTs any of those additional medications there needs to be a lot of education about them on the EMT level.

 

[Dennhop]

On the subject of etco2, may as well move that to an EMT-B level, since EMT-B can place nonvisualized airways, such as king's or combitubes...

 

[SpecialK]

@SpecialK all great stuff. Only one small snag...'murrica.

So what you are saying is America is not a developed first world nation which wants its ambulance personnel to be able to look after their patients if they are not at Paramedic or ICP equivalent levels ... right.

Well, you're not saying that obviously (I am joking) so ....

 

[Carlos Danger]

Remi, I'd love for you to elaborate, and I'm not being a smartarse here either.

How do we de-emphasize, yet still remain proficient? Do you think that's a reality? Should it only be left for certain (specialty certificate) providers?

Also, where--if at all--do you think RSI fits into prehospital medicine?

I'm not really talking about proficiency, as I don't think most paramedics graduating from most paramedic programs are proficient in the skill anyway. I think it should be de-emphasized both in protocols and training programs. But I still think it should probably be taught.

Kind of like (<paramedic instructor speaking> "now that we've spent a lot of time on respiratory physiology, mechanical ventilation, mask ventilation, and SGA's, we're going to go over endotracheal intubation. This is something that you probably won't do, at least not until you are further on in your career and go to work for a HEMS program or something along those lines, at which time you'll get a lot more training on it. But it is a skill that every paramedic should have had at least some exposure to".

I think there are some settings where ETI and RSI makes sense to have in your protocols, but I think it should be reserved for agencies that have more of a need for it, and have relatively small numbers of paramedics, heavy med director involvement in training and QI, and some opportunity for frequent training on it.

 

[EpiEMS]

What about the following?

Entonox or methoxyflurane (I can't believe you guys don't have either of these!)

'Murica, man - the FDA pulled them, I believe. That said, nitrous is in AEMT scope.

GTN

Administration of patient's own is in EMT scope, and AEMT scope includes SL nitro (GTN).

12 lead ECG acquisition

That's a good one - and there is a good evidence base for EMS 12-leads speeding door-to-balloon time, though I'm not sure if it extends to those done by (non-interpreting) BLS providers.

Salbutamol and ipratropium

Administering patient's own inhalers is in EMT scope, AEMT includes administration of inhaled beta agonists, not just the patient's own.

IM midazolam for status epilepticus

Not so likely - narcotics raise a whole set of control issues. It's not in AEMT scope. Not sure how much evidence there is that IM midazolam is used frequently enough, anyway?

IM adrenaline (from a syringe - why bother with a bloody autoinjector?)

I totally agree - that being said, people are scared about EMTs doing anything "invasive". This is coming around throughout the country, but I think cost of autoinjectors will fall precipitously soon enough.

IM and IN naloxone (you blokes probably use it a bunch)

Absolutely - I think they're already considering this.

IM glucagon (if you can take a BGL why can't you treat hypoglycaemia)

As with the autoinjector - I'm 100% with ya, this'd be good at the EMT level. It is already in-scope for AEMTs.

Oral ondansetron

Ooh, I like this one. The ability to reduce nausea would be excellent. Not sure about downside risk of Zofran at the EMT level, though. Maybe just give it to AEMTs?

 

[hometownmedic5]

It is in the New Hampshire bls scope to acquire and transmit 12lds without interpretation. I don't know if any services are actually providing 30k dollar monitors to basics, but on paper it's allowed.

 

[hometownmedic5]

In a perfect world, aemt would be entry level to staff an ambulance(with most if not all of the above); but we know that will never happen. You don't need to be advanced to do the renal round up or haul nana to the manor, and that's primarily the job description of BLS.

 

[EpiEMS]

It is in the New Hampshire bls scope to acquire and transmit 12lds without interpretation. I don't know if any services are actually providing 30k dollar monitors to basics, but on paper it's allowed.

It's in CT and NY protocols, too - there are options that are cheaper, e.g. the ReadyLink

In a perfect world, aemt would be entry level to staff an ambulance(with most if not all of the above); but we know that will never happen. You don't need to be advanced to do the renal round up or haul nana to the manor, and that's primarily the job description of BLS.

I absolutely agree - but in this world that we have now, EMT is the basic level, so I don't see a problem in upskilling EMTs slightly (and obviously increasing the length of the curriculum commensurately).

 

[hometownmedic5]

It's in CT and NY protocols, too - there are options that are cheaper, e.g. the ReadyLink



I absolutely agree - but in this world that we have now, EMT is the basic level, so I don't see a problem in upskilling EMTs slightly (and obviously increasing the length of the curriculum commensurately).

Adding to the emt training to increase skills, add some knowledge and end up with an expanded scope; but not arriving at the true ALS level. That sure sounds like advanced emt to me.

Then again, since day one, ems in this country has been about appearances and half measures. We created emt-I as a stepping stone between b and p. Now, you're suggesting a stone between b and I?

What we need is to dump I altogether. Raise bls to ils, keep paramedic, and in a perfect world id love to see ccp as the first step to a college requirement. It would be such a beautifully smooth transition. At first, just the cc medics need a degree(associates). A few years go by, cc becomes a bachelors, medic becomes an associates. Hell, maybe even someday we go one more step and make critical care paramedics mid level providers and maybe finally get a seat at the table.

Oh what a world that could be...

 

[EpiEMS]

Then again, since day one, ems in this country has been about appearances and half measures. We created emt-I as a stepping stone between b and p. Now, you're suggesting a stone between b and I?

Given that measures like epinephrine autoinjectors, CPAP, and BLS 12 lead acquisition are fairly commonplace (or safe and evidence based practice that ought to be adopted), I'm not seeing the issue with adding it to the scope of practice model. Your concern seems broader, to me, than the SOP model.