What if EMT/Paramedic was one program instead of 2?

[NYMedic828]

So we always bring up why even have EMTs when you could just staff paramedics. Well I want to talk about why even require EMT before medic?

People always drop the BS line of "you should have some field experience before you go for medic." Which is nonsense. Often it leads to people getting set in a job and not even returning for medic and its just nonsense to slow you down and allow people to feel more empowered in their "higher" position than you. You don't need to be an RN or PA first to become an MD. (Yea yea RN -> NP don't care)

I am sure people have different experiences than my own but I can honestly say that nothing in my EMT class wasn't covered all over again in more depth, in my medic program.

So why even waste 200-300 some-odd hours in an EMT class? 300 hours, in the grand scheme is not that much but in a base level certification program that is another 5-8 weeks of learning more material rather than essentially wasted hours in repetition. Another 5-8 weeks of pharmacology or anatomy can go a long way...


I am not really looking to get into "well why not just extend the medic program in general." We all know that needs to happen, but its not the point I am raising.

 

[usalsfyre]

So we always bring up why even have EMTs when you could just staff paramedics. Well I want to talk about why even require EMT before medic?

People always drop the BS line of "you should have some field experience before you go for medic." Which is nonsense. Often it leads to people getting set in a job and not even returning for medic and its just nonsense to slow you down and allow people to feel more empowered in their "higher" position than you. You don't need to be an RN or PA first to become an MD. (Yea yea RN -> NP don't care)

I am sure people have different experiences than my own but I can honestly say that nothing in my EMT class wasn't covered all over again in more depth, in my medic program.

So why even waste 200-300 some-odd hours in an EMT class? 300 hours, in the grand scheme is not that much but in a base level certification program that is another 5-8 weeks of learning more material rather than essentially wasted hours in repetition. Another 5-8 weeks of pharmacology or anatomy can go a long way...


I am not really looking to get into "well why not just extend the medic program in general." We all know that needs to happen, but its not the point I am raising.

Ideally you'd have a level of provider that was similar to an AEMT as the entry point with a small corps of paramedics...

 

[NYMedic828]

Ideally you'd have a level of provider that was similar to an AEMT as the entry point with a small corps of paramedics...

Not sure what you mean?

I am suggesting allowing those who choose to, to go right into paramedic school instead of having to take an EMT program first, and adding the time of an EMT course onto a paramedic one.

No EMT class, longer paramedic class. Difference being, time is not wasted repeating already learned material.

 

[usalsfyre]

Not sure what you mean?

I am suggesting allowing those who choose to, to go right into paramedic school instead of having to take an EMT program first, and adding the time of an EMT course onto a paramedic one.

No EMT class, longer paramedic class. Difference being, time is not wasted repeating already learned material.

We don't need more paramedic level providers running around than we have. In fact, we have far too many paramedic level providers running around. Look at how South Africa and Aus organize their systems.

 

[medic417]

Actually there are some colleges that offer a Paramedic degree that includes the emt basic as part of the first semester.

 

[Medic Tim]

Where I live and work there are no emts. We have first responders which are usually always fire fighters. Primary care paramedics and advanced care paramedics. You do not have to be a first responder to go to medic school. PCP school is from 9 months to 2 years full time study depending on the program and province. The skill set is very similar to the aemt in the us. In some very rural communities in Canada there are first responders which is the same or higher than a basic in the is , that work on ambulances. In most all areas the PCP is the minimum to work on a truck. Some work in ers as triage or er techs as you call them in the us. After a few years as a PCP you can be selected for ACP training or enroll yourself on your own dime. This is usually 1-2 more years of education and can be done hybrid or full time in class. The scope is a bit higher than the nremtp . After that is critical care paramedic . Another 1-2 years of education after experience as an ACP .

The cost of our programs is also quite high. I just saw one advertised for 14k. And each step uP in lever costs about the same unless you are sponsored by an agency.

Starting Pay varies prom province to province but most start low to mid 20s an hour. Some are into the 30s.
Ems is not just a job here. Many get into It to be a medic and not branch off into something else.

 

[Jambi]

No reason why it couldn't be, but I'd think that to be most successful programs would have to move away from the vocational model and more towards what Canada does.

 

[DrParasite]

So we always bring up why even have EMTs when you could just staff paramedics. Well I want to talk about why even require EMT before medic?

why not?

People always drop the BS line of "you should have some field experience before you go for medic." Which is nonsense. Often it leads to people getting set in a job and not even returning for medic and its just nonsense to slow you down and allow people to feel more empowered in their "higher" position than you. You don't need to be an RN or PA first to become an MD. (Yea yea RN -> NP don't care)

great example RN -> NP that you totally ignore. not only that, but an RN and MD have different jobs, different educations levels, and are completely different. ditto RN and PA. In order to be a cardiologist, you need to be an MD first. in order to be a thoracic surgeon, you need to be an MD first. see the connection?

I am sure people have different experiences than my own but I can honestly say that nothing in my EMT class wasn't covered all over again in more depth, in my medic program.

probably right.

So why even waste 200-300 some-odd hours in an EMT class? 300 hours, in the grand scheme is not that much but in a base level certification program that is another 5-8 weeks of learning more material rather than essentially wasted hours in repetition. Another 5-8 weeks of pharmacology or anatomy can go a long way...

your EMT class is 200-300 hours? damn, mine was only 110, but they are increasing it to 160 (I think). Not only that, but going 9am to 5pm monday to friday will complete that class in 4 weeks. if a paramedic program is 1000 hours, you are talking about another 20 weeks of training, not just 5-8. Some paramedic programs are 2 year programs.

You work in NYC right? did you ever do BLS there? do you think the majority of those patients that were dispatched as BLS only needed a paramedic? If you had an all paramedic system in NYC, how many sick patients would you actually see?

I don't think everyone needs a paramedic assessment. i think EMTs need more experience, but I really haven't seen anything that makes me think that a paramedic will save more lives. I think they need more training too, but I think if you make everyone a paramedic you will have a dilution of skills, and end up with crappy medics like you have in Cali (due to ever firefighter, ambulance jockey, garbage man, and DPW employee) because they never see or treat sick patients.

One of the most important things EMTs should learn is how to do an assessment. yes, they need more practice in real life under the supervision of an experienced provider, but they should know how to do an assessment, and should know sick vs not sick. Sometimes you need to screw up to learn how to do things right (that is what experience is all about right?), and the more patient contacts you have, typically the better provider you will be. But there are some scary paramedics in high volume systems.

 

[hibiti87]

there is of course also the issue of actually wanting to do the job once you have completed school. No one talks about C.diff in the class room, but when your out in the field and the ..... hits the fan so to say, you learn quickly if you have the stomach for the job. Becoming an EMT is a good way of easing people into the profession in my opinion.

 

[Frogil]

Yeah I do support this and it is quite true.

 

[akflightmedic]

Yeah I do support this and it is quite true.

What is? Can you explain in more detail and present a solid opinion or are we just filling a post requirement?

 

[NYMedic828]

Yeah I do support this and it is quite true.

??????

 

[WestMetroMedic]

I think that the idea of getting rid of the EMT-Basic level would debilitate those agencies who are not urban and suburban.

Minnesota, a state of roughly 5,000,000 people has roughly 300 licensed ambulance services. Of those, i suspect less than 25% of those are licensed at the Advanced Life Support level. Why? Because they are rural agencies that rely on volunteers (albeit paid-on-call, but volunteers none the less) who want to serve their community. If volunteers were expected to complete 2 years of education in order to help their neighbors out, we would run into a serious problem. Small, rural communities cannot afford ALS. It is expensive, prohibitive and not in their best interest.

These areas have access to advanced level providers via fixed and rotor wing services and also they may have access via a neighboring ALS agency.

Look at Boston, a well respected service, they have about a 8 to 1 BLS unit to ALS unit ratio. They have plenty of EMT-Basics who make a good living and enjoy their job i suspect. If you make jack squat as a basic, perhaps you are in the wrong market (see:SoCal).

OPALS showed that Basics have better outcomes for the big stuff and Paramedics earn their keep by reducing hospital admission time for the meat and potatoes calls.

 

[MrJones]

Actually there are some colleges that offer a Paramedic degree that includes the emt basic as part of the first semester.

The medic program I'm in uses that model.

 

[EpiEMS]

OPALS showed that Basics have better outcomes for the big stuff and Paramedics earn their keep by reducing hospital admission time for the meat and potatoes calls.

I'm looking at OPALS (the first paper, I think?) now, and they came to a very clear conclusion: "systemwide implementation of full advanced life-support pro- grams did not decrease mortality or morbidity for major trauma patients. We also found that during the advanced life- support phase, mortality was greater among patients with Glasgow Coma Scale scores less than 9." The full paper for OPALS is here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292763/pdf/20080422s00017p1141.pdf

For trauma, BLS seems to produce outcomes that are as good as (or better than) ALS. Granted, metrics such as pain control were not considered, but from a system design perspective, outcomes like survival to discharge and how intact people's lives are after discharge should take primacy.

For cardiac arrests, ALS seems to be unhelpful: lots of ALS interventions get in the way of good, quality CPR, and don't necessarily help with getting defibrillation done -- a BLS AED works just fine. After all, even the AHA admits there's no evidence basis for ACLS. RogueMedic (the blog) gives an excellent summary of why cardiac arrest management is a BLS skill (http://roguemedic.com/2011/12/cardiac-arrest-management-is-an-emt-basic-skill/).

As far as general medical calls, there's where ALS can really shine, I'd wager. Then again, for your run-of-the-mill diabetic call, an EMT with a glucometer is just fine.

 

[JakeEMTP]

I'm looking at OPALS (the first paper, I think?) now, and they came to a very clear conclusion: "systemwide implementation of full advanced life-support pro- grams did not decrease mortality or morbidity for major trauma patients. We also found that during the advanced life- support phase, mortality was greater among patients with Glasgow Coma Scale scores less than 9." The full paper for OPALS is here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292763/pdf/20080422s00017p1141.pdf

For trauma, BLS seems to produce outcomes that are as good as (or better than) ALS. Granted, metrics such as pain control were not considered, but from a system design perspective, outcomes like survival to discharge and how intact people's lives are after discharge should take primacy.

For cardiac arrests, ALS seems to be unhelpful: lots of ALS interventions get in the way of good, quality CPR, and don't necessarily help with getting defibrillation done -- a BLS AED works just fine. After all, even the AHA admits there's no evidence basis for ACLS. RogueMedic (the blog) gives an excellent summary of why cardiac arrest management is a BLS skill (http://roguemedic.com/2011/12/cardiac-arrest-management-is-an-emt-basic-skill/).

As far as general medical calls, there's where ALS can really shine, I'd wager. Then again, for your run-of-the-mill diabetic call, an EMT with a glucometer is just fine.

How do you think OPALS compares with the US EMS levels? The "BLS" providers in that study spend over 2x longer training and getting an education than most US Paramedics do in their programs. The PCP is a two year program. They have the educatiion to back up an asssesment to determine the appropriate interventions. This study does is not about the BLS EMT in the US with a 120 hour very basic course and no A&P.

http://www.ontarioparamedic.ca/index.php/paramedics/levels-and-scope-of-practice

This could be interpreted as a study that a better educated EMT could make a difference.

As for the cardiac side, what happens if you do get ROSC with an AED? How do you as an EMT plan to support circulation? What pressors do you carry as an EMT? What about initiating a hypothermia protocol?

 

[EpiEMS]

This study does is not about the BLS EMT in the US with a 120 hour very basic course and no A&P.

Actually, as far as procedures performed goes, it is. The study is very specific: "Advanced life-support protocols include advanced airway management (endotracheal intubation) and intravenous fluid therapy. In contrast, basic life-support providers administer oxygen, ventilate with a bag valve mask, and provide immobilization and dressings." Similarly, reference Table 1. It indicates BLS providers performed 0 initiations of IV fluids and 0 tube placements.

Not to mention, the PCP scope in Ontario is most similar to an EMT with an IV endorsement -- not even close to EMT-P. (http://health.gov.on.ca/english/public/program/ehs/qa/edu_qa.html#6)

Again, the link to OPALS: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292763/

As for the cardiac side, what happens if you do get ROSC with an AED? How do you as an EMT plan to support circulation? What pressors do you carry as an EMT? What about initiating a hypothermia protocol?

Can't argue with that, other than to say that the data on survival to discharge shows that BLS does as well as ALS.

 

[Akulahawk]

I think it would be absolutely wonderful if an EMT could get even 3-400 hours instructional time in doing assessments. While their interventions may not be any greater than what we get now, they'd have a better ability to assess and determine if a more advanced provider as needed, and how better to deliver that patient to said provider.

 

[JakeEMTP]

Actually, as far as procedures performed goes, it is. The study is very specific: "Advanced life-support protocols include advanced airway management (endotracheal intubation) and intravenous fluid therapy. In contrast, basic life-support providers administer oxygen, ventilate with a bag valve mask, and provide immobilization and dressings." Similarly, reference Table 1. It indicates BLS providers performed 0 initiations of IV fluids and 0 tube placements.

Not to mention, the PCP scope in Ontario is most similar to an EMT with an IV endorsement -- not even close to EMT-P. (http://health.gov.on.ca/english/public/program/ehs/qa/edu_qa.html#6)

Again, the link to OPALS: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292763/



Can't argue with that, other than to say that the data on survival to discharge shows that BLS does as well as ALS.

You are attempting to equate skills and are missing the education part. But, if it is just skills you are looking for, I did post the PCP skills in my previous post.

No the PCP is not like the EMT with an IV endorsement. You can not compare the PCP to an EMT with a 110 hour cert and an extra 2 hours for an IV endorsement. Their 2 years of education probably has more clinical hours than the total hours of some US Paramedic programs. The US EMT averages maybe 20 hours of clinicals which are sometimes wasted doing very little in unstructured churn 'em out programs. During the 2 year program the PCP student may actually become very proficient at performing basic skills such as using a BVM, assessing, packaging and even taking a BP. Plus, as an added bonus they will actually know why they are doing all of those basic skills and what to do with the information they get from their assessment.

 

[Akulahawk]

You are attempting to equate skills and are missing the education part. But, if it is just skills you are looking for, I did post the PCP skills in my previous post.

No the PCP is not like the EMT with an IV endorsement. You can not compare the PCP to an EMT with a 110 hour cert and an extra 2 hours for an IV endorsement. Their 2 years of education probably has more clinical hours than the total hours of some US Paramedic programs. The US EMT averages maybe 20 hours of clinicals which are sometimes wasted doing very little in unstructured churn 'em out programs. During the 2 year program the PCP student may actually become very proficient at performing basic skills such as using a BVM, assessing, packaging and even taking a BP. Plus, as an added bonus they will actually know why they are doing all of those basic skills and what to do with the information they get from their assessment.

That is probably the biggest difference between a PCP and a US EMT. The interventions they may perform might be roughly equivalent between the two, in terms of actual skills that may be employed, but the PCP will probably have a greater understanding of the reasons behind the application of those skills and a better guided education in being able to do an assessment than the typical US EMT.

I would imagine that those particular skills were chosen because they represent an easy demarcation line between a PCP and a higher level of provider that can perform typical ALS level skills. There will, no doubt, be a significant difference between the two levels of providers in terms of education. Despite that, there may be differences or issues with the study. It is possible that there is a selection bias towards the higher level provider being sent to more "sick" patients. That would be in line with not seeing much of a difference between the two in terms of outcome.

If anything, I would expect that the study would show that simply getting a patient rolling towards the hospital sooner is better than getting advanced procedures started on scene and then starting transport. As a paramedic myself, when it comes to trauma patients, I tend to think like a basic – get the patient extricated, get them in the truck, do everything else in route. For trauma patients, I have an extreme dislike for being on scene greater than 5 min. That does not mean that I might drive the patient code 3 to the hospital, it means that I want the patient heading to the hospital sooner rather than later.