Proposed EMS Scope of Practice Model

[disassociative]

Some of you may be familiar with "Dr. Brian Bledsoe's Scope of Practice Model for EMS", others may not. However, I encourage you to review this article from the <i>Journal of EMS</i> by clicking the following link:

http://www.jems.com/news_and_articles/columns/Bledsoe/Bledsoes_EMS_Scope_of_Practice_Model.html

What do you think about this scope of practice model? Why?

 

[Flight-LP]

It has already occured in some areas, but until we make some radical, unpopular changes such as eliminating volunteers and stop allowing BLS units to operate as primary 911, it will never materialize. Until we can COMPLETELY regulate and eliminate the backwoods good 'ol boy persona that plagues many agencies, we will be stagnant in our efforts. Until we realize that a 120 hour first aid course does not properly prepare an 18 year old kid to operate on an ambulance, EMS will be just as it is today............A vocational trade.

 

[Ridryder911]

Although, it would be nice to have a somewhat formal scope of practice, I do not like Bledsoe's "dream. Again, too many levels. Why is we think we have to have so many 8%##! levels?

Why not, educate Paramedics properly, then they can specialize into an area, like physicians, nurse, and the rest of the medical community.

The problem is again the old adage of volunteers and lower levels, as well getting Medicare and other insurance payors to properly reimburse EMS.

R/r 911

 

[seanm028]

Until we realize that a 120 hour first aid course does not properly prepare an 18 year old kid to operate on an ambulance, EMS will be just as it is today............A vocational trade.

Are you suggesting that the minimum age needs to be raised?

 

[Flight-LP]

Indirectly, I suppose yes. Since Paramedic education should be at a minimum an associate level degree, it would be difficult to obtain at the age of 18. Age isn't so much of a factor, but an 18 year old with only an EMT-B course is substantially less prepared to actually intervene for a patient than a 20 year old with 2 solid years of true education including specific knowledge in pharmacology, anatomy, and pathophysiology of disease. I also would like to see more focus on teaching student on how to correlate knowledge in addition to application of knowledge. The EMT-B level offers only rote memorization with an emphasis on simplistic skills. There is a huge difference between the two.

But as usual, Rid has a very valid point. Even Dr. B himself proposes too many levels. But at least his levels focus on a Paramedic education as the core instead of 30 million different lower level titles. Yeah, in a perfect world there would be a Paramedic and an advanced Paramedic running primary 911 EMS. Nothing less. But we all know how perfect our world truly is. Maybe in my lifetime we'll see it, who knows......................................

 

[seanm028]

Well, I can see what you're saying. I'm 18 and I just obtained my EMT-B four months ago, but on the other hand, I guess I'm going at my EMS career a little differently than most.

A lot of my family has been in medicine, so I've had exposure to it all my life. I also have no intention of stopping at the basic level; it's sort of a stepping stone. My university doesn't have any EMS classes, but I am taking some nursing courses (human development, A&P, microbiology, healthcare organizations and ethics, etc). Unfortunately, the community college where I got my EMT-B education only accepts students into their paramedic program if the student it currently employed by a private ambulance service or fire department. I'm trying to get hired with an ambulance service, but there's a lot of competition.

Basically, I think the difference for me is that I intend to continue educating myself in EMS and I'm consistently supplementing my training with whatever material I can get my hands on (a friend just loaned me his EMT-P textbook and some material on arrhythmias... not quite within my scope of practice, but I think good general knowledge and hopefully it will help when I eventually find my way into a paramedicine program).

 

[daedalus]

I, too, am 18 years old. Finished EMT not to long ago. And I have been exposed to medicine my entire life as well. I grew up in my grandfathers practice. He is a (recently retired) family doc, my mother, grandmother, and great grandmother are/were RNs. I have volunteered for three years at a local free medical clinic and shadowed many doctors there. I have taken advanced Biology and Honors A and P. What sets me apart from some 18 year old with a cert, is that, i can approach a patient. I have done it for three years. The doc and me would go in, i would assist with his history and while he assesed the pt, i was right there listening to lung/heart sounds, looking in ears... After that when we left he would discuss the disease process or injury with me. I realise not every person my age has done these things, however, age should not be used to judge an EMT or paramedic. Their knowledge and ability is far more importance.

Cheers

 

[disassociative]

I would like to see the various non-paramedic level EMT designations be consolidated into: EMT and EMT Advanced, instead of one state having EMT-IV, while another has EMT-Shock Trauma's, etc. I think that the outlined scope of practice for these provider levels is more than suitable; given that the education time reflects that of the skills being taught. We have had EMT-IV's here for as long as I can remember; NREMT-B with extra training in a TN approved EMT-IV program lasting 1 yr. These providers cannot drop ET's however they can use combitubes, PtL, LMA, start IV's, run d50w/d25w, and administer the standard EMT-B line of meds(SL Ntg, Activated Charcoal, Epi 1:1000 SubQ and Epi-Pen). I like Rid's idea with regard to Paramedic specialties such as in nursing in which an RN can pursue further specialization in a specific area: Ob/Gyn, Critical Care, Med/Surg, Geriatrics, etc. I see nothing wrong with consolidating the various entry-level EMT-B rankings into one system allowing for this larger scope of practice; however, if we are going to give these EMT-B's these skills; we must give them the appropriate training; no more of this 120 hr $#%#. As for Paramedics; formal education & licensure(A.A.S., B.S., M.S.).

I encourage you to research: Paramedic Intensivists; and Paramedic Practitioners.

 

[medicdan]

I am 18 years old and have been certified for six months. From my perspective, the issue is not one’s age, but the nature of EMT-B training. I had a very good University-based course, but I agree with those who have noted that 120 hours (my course was actually 150 hours) is not sufficient to allow one to understand the range of problems and treatment protocols one needed in the field. I’m doing a “gap year” before going to college and have been volunteering ever since I was certified. I’ve had experience now with almost 150 patients. I’ve learned more in the field than I did in my course (partly because I have worked with great paramedics and (because 3 months of my experience was in Israel) with MDs.

At this point, I have no problem acting as a second pair of hands stabilizing and transporting patients with a more expierence partner. I feel competent supervising (monitoring) and stabilizing patients while rapidly transporting (evacuating) to the hospital. I feel comfortable doing the equivalent of non-emergency transports. I also feel very comfortable calling for ALS backup if help is needed. The reason I now feel comfortable is that I have had good clinical experience. If anything is changed, it should be to require internships and more clinical experience. There is a big gap between classroom discussions/simulations and actual practice.

Although I don’t think age should be a barrier to practice, clearly maturity is needed. Perhaps many 18 year olds are not ready for the responsibility of being in the field. But I suspect there are more than a few 21+ year olds who are not ready (judging from some of the stupid things I have seen patients and even EMTs do). More stringent clinical requirements would level the field and ensure that only qualified people are allowed to provide unsupervised patient care.

 

[Flight-LP]

I, too, am 18 years old. Finished EMT not to long ago. And I have been exposed to medicine my entire life as well. I grew up in my grandfathers practice. He is a (recently retired) family doc, my mother, grandmother, and great grandmother are/were RNs. I have volunteered for three years at a local free medical clinic and shadowed many doctors there. I have taken advanced Biology and Honors A and P. What sets me apart from some 18 year old with a cert, is that, i can approach a patient. I have done it for three years. The doc and me would go in, i would assist with his history and while he assesed the pt, i was right there listening to lung/heart sounds, looking in ears... After that when we left he would discuss the disease process or injury with me. I realise not every person my age has done these things, however, age should not be used to judge an EMT or paramedic. Their knowledge and ability is far more importance.

Cheers

This is true to a certain level, however you have to realize that EMT's are also exposed to at least 10 year of education, yet most do not take an ounce of it with them into a career in EMS. Your "applicable" experience is indirect and while helpful in getting you acclimated with an introduction into healthcare, it does not greatly assist you in becoming an EMT.

Too much emphasis on the age statement I made. That was not my point. The point was that education standards are currently sub par for lower level providers, hence the fact that they should not be responsible for primary 911 response. Sorry for the perceived confusion.................................

 

[Ridryder911]

Heck.. I will jump with both feet first into the matter..! (as I always do) Yes, there should be age restrictions. Simply put, most of those under the age of 21 (in which we have to use) are not able to make critical decision making problems. This has been proven scientifically per research and even per thermal image CT scans. The brain does not mature until about the age of 21, in the reasoning and logistics area. This is nothing new. Insurance corporations, even the military has known this for years. The same reason most Law Enforcement agencies do not allow anyone < 21 years of age.

As well, medicine is an art as much as it is science. Sure, anyone can spit out treatment protocols, facts and figures, if they are intelligent. The difference is to understand the appropriate time and the human aspect. Having life experience is a critical point of making rational non rash decisions. Exposure to traumatic events such as what the EMT sees everyday can be detrimental to those that are still developing mentally. It is even dangerous to those that already have, why cause more problems.

Personally, I do not worry about the age problem. Insurance corporations are already dealing with that. Denying coverage for drivers <21 to 23 and now some are denying malpractice coverage for those < 21.

Yes, there are exceptions. I am quite aware of them, and have seen many prime examples of immature 40 year olds, and mature 17 year olds. I even received my Paramedic when I was 17, so yes I can understand. It is that in the general population, we have to categorize them.

R/r 911

 

[disassociative]

Ever wondered why the legal drinking age was 21?

I think Rid just answered that one.

 

[skyemt]

It has already occured in some areas, but until we make some radical, unpopular changes such as eliminating volunteers and stop allowing BLS units to operate as primary 911, it will never materialize...

Flight-LP, I work for a volly agency, where BLS operates as primary 911. We have ALS, paramedics when needed... it works very, very well. i would like to know why it didn't work for you when you worked volly 911... would like to compare notes.

of course, if you haven't worked in such a system....

 

[Flight-LP]

Its really quite simple, every patient deserves a thorough assessment and intervention from the highest available level of care possible. That is NOT an EMT-B. It is currently accepted to be a Paramedic. I have heard almost every excuse as to why this "is not possible". The bottom line is that communities that do not provide this service do so due to fiscal reasons. If it is acceptable in your community, then great. But my community demands a high quality Paramedic level service and they gladly pay for it. We are successful in what we do and it maintains a level of pride and professionalism.

When you look nationwide at volunteer systems, you will notice two things. 1) the numbers are on the decline, and 2) they are mostly BLS services. Why is that? Because not too many people who advance to a career level Paramedic training are willing to do the job for free. I know I certainly won't. I will not devalue myself to do a job that others are getting compensated for, just for the sole "opportunity" to do it. On the flip side, everytime a Paramedic volunteers, it gives an employer one more reason to not pay ME or pay me less. That is just purely unacceptable.

Communities will have to realize that you do not get quality for free. You get what you pay for. Want a high quality service, well guess what, you're going to get taxed for it. Don't want to pay for it, well enjoy your BLS service and hope that they do not financially go under. Then you have NO EMS.............

Don't believe me or agree????????? Tell me when you last saw a trash man that volunteered to do his job or a community that didn't pay for his service.

 

[skyemt]

Flight-LP,

as i stated before, we are volly, but not limited to emt-b... we have quite enough paramedic ALS for those that need it. a twisted ankle does not require a medic. a laceration to the arm does not require a medic... stable "sick" pt's do not require medics. when a pt does need one, ALS is provided. Does this not meet your criteria? Our ALS is volly, and they care solely about the pt, and don't really care about your job security. It is purely about pt care. in some ways, preferable to the system you work in, from the sounds of it.

Also, since you have not worked in a system such as ours, you are entitled to your opinion, but you really have no idea what you are talking about.

the issue here isn't emt-b vs paramedic, as you keep wanting it to be.

the issue is that in different parts of the country, different types of systems DO work. Perhaps you could think about considering what works in different situations, instead of blindly disparaging those that are different.

 

[bstone]

Ever wondered why the legal drinking age was 21?

I think Rid just answered that one.

Only in this country. Everywhere else it's 18. I once worked at a cafe in Israel and we didn't even card. Alcohol there is just totally different. The only people falling over drunk were the American tourists.

 

[Jolt]

Its really quite simple, every patient deserves a thorough assessment and intervention from the highest available level of care possible.

Then why don't MDs respond to every call? Rid has said a few times that he assisted in a field amputation which must have been performed by a physician. The physician wasn't immediately dispatched to the call, he/she was called once the next lower qualification (in this case a paramedic) decided that he/she was needed.

It's a moot point, but maybe one to think about. Why can't EMTs go on calls and bring in paramedics when they realize that the higher level of care is needed? It works for many systems. At the very least, BLS crews can do CPR until an EMT-P arrives to take over. That way, the paramedic is freed up to do only the important calls and not the frivolous twisted ankles and stubbed toes.

With that said, I would be more than happy to do at least another 200 hours of training if it made everyone happy. It's pretty discouraging to me as a rookie to hear that no one wants me within 100 feet of their patients.

 

[Flight-LP]

Flight-LP,

as i stated before, we are volly, but not limited to emt-b... we have quite enough paramedic ALS for those that need it. a twisted ankle does not require a medic. a laceration to the arm does not require a medic... stable "sick" pt's do not require medics. when a pt does need one, ALS is provided. Does this not meet your criteria? Our ALS is volly, and they care solely about the pt, and don't really care about your job security. It is purely about pt care. in some ways, preferable to the system you work in, from the sounds of it.

Also, since you have not worked in a system such as ours, you are entitled to your opinion, but you really have no idea what you are talking about.

the issue here isn't emt-b vs paramedic, as you keep wanting it to be.

the issue is that in different parts of the country, different types of systems DO work. Perhaps you could think about considering what works in different situations, instead of blindly disparaging those that are different.

Simmer down and read it again......................

If it works for your community and they accept it then great, but not all do...

What defines stability in the sick person?

Does the twisted ankle not deserve pain control?

What about IV access for the pt. with the contaminated laceration to his arm. Will he/she not be needing IV antibiotics?

Its not about just getting them to an ER, it is about being a part of the collaborative health care team. Personally, that is what I provide for my patients, therefore your personal belief concerning my level is care is irrelevant.

I am not "blindly disparaging" anyone. I have a fair amount of insight into this industry and many geographic and demographic specific systems. My belief is based on collection of information from all of these systems I have dealt with, whether it be as an employee, a contractor, or a consultant. These are my beliefs and those shared by many others. It is not designed to be taken as gospel, so don't over analyze it.............................

 

[Flight-LP]

Then why don't MDs respond to every call? Rid has said a few times that he assisted in a field amputation which must have been performed by a physician. The physician wasn't immediately dispatched to the call, he/she was called once the next lower qualification (in this case a paramedic) decided that he/she was needed.

It's a moot point, but maybe one to think about. Why can't EMTs go on calls and bring in paramedics when they realize that the higher level of care is needed? It works for many systems. At the very least, BLS crews can do CPR until an EMT-P arrives to take over. That way, the paramedic is freed up to do only the important calls and not the frivolous twisted ankles and stubbed toes.

With that said, I would be more than happy to do at least another 200 hours of training if it made everyone happy. It's pretty discouraging to me as a rookie to hear that no one wants me within 100 feet of their patients.

Key word is available. Here in the US as we do not value our EMS systems enough, we do not provide sufficient compensation to staff a physician run ambulance. Even if we did, it still wouldn't work until this country stops allowing frivilous ambulance chasing lawsuits. Very few MD's would want the liability of being directly involved in pre-hospital care.................

As stated in my last post, I still see that each of these pts. deserve a medic from the initial contact. Especially the CPR patient. How will you as an EMT-B provide access for anti-dysrhythmic medications? What about securing an airway? What about post resuscitative care should you immediately convert the patient?

The thought of keeping a Paramedic available is a nice one, I will admit. But when it comes down to dollars and cents, if the money is there to provide for a medic and obtain reimbursement for a medic, then how could you not think about providing one? If the money isn't there, and that is the reason, then you should be asking yourself why? Are you not billing? Do you not tax? These are strong forms of revenue and, again, since this country does not provide adequate healthcare subsidies, then that money needs to be generated somewhere. It still falls down to "you get what you pay for".......

I'd pay for quality any day of the week and twice on Sunday!

 

[Jolt]

How will you as an EMT-B provide access for anti-dysrhythmic medications? What about securing an airway?

These two problems were actually addressed in the proposed scope of practice (allowing EMTs to place IVs and combitubes). I think another 40-50 hours would be sufficient to teach those skills without increasing class times too much.