UMSTUDENT

I'm torn on RSI, but typically believe it should be something that is part of the "universal paramedic toolbox." Why? I've watched so many dumb things happen to patients who truly needed it and where it wasn't available, e.g. head injured, clenched patient who has three paramedics desperately trying to nasally intubate as saturations drop below 80% with poor BVM compliance (with NPA placed). No matter which way you shake it, this patient is going to die if airway access is not achieved relatively quickly. We don't have RSI in my jurisdiction, but I have intubated both sedated (as part of routine clinicals) and non-sedated patients and can generally say that the paralyzed patient tends to be some of the easiest I've performed. It seems counterintuitive that we would ask our paramedics to intubate in a more difficult fashion and then hold them accountable for the success rates they receive in this austere, less than perfect situation. Then again, I don't personally see what all the "paramedics can't intubate" controversy is about. The advent of ETCO2 waveform capnography seems to have really limited the instances of unrecognized esophageal intubation and better education and fear mongering has really gotten most to realize the importance of confirming an airway. Really, in my opinion, every jurisdiction should have a robust airway training program which includes hospital time quarterly. The only way, in my opinion, to get good at intubation is to do it a lot, particularly as a new paramedic. I felt like I received this during my first job in a high call volume environment, but many paramedics never receive this exposure, particularly in a rural environment. I feel that where states should get involved in EMS is in things like this. States should pass legislation mandating hospital participation in EMS training programs and provide subsidized premiums for anesthesiologists who allow paramedic intubation. A paramedic should intubate four times quarterly or BAM-automatic OR time.

Is there anywhere I could read some good literature on New Zealand's system? Sounds pretty good.

First, thanks for searching. I'm sure plenty of people are privately commending you for using the feature. Second, my EMS system is not progressive. Where I work the protocols are statewide and widely considered "conservative." I used to say "not progressive at all," but recently the state has made some leaps towards accepted practices like CPAP, nitrates for acute pulmonary edema, and now corticosteroids for asthma. None of these things are cutting edge, in fact I'd say they're really just the accepted standard of care, but it's an improvement from even 5-6 years ago when no amount of literature could have convinced them to step toward the future. We're still flowing high flow oxygen on pretty much everything, rushing every cardiac arrest to the hospital, intubating everything under the sun, and just starting to pilot hypothermia (in limited ways). The protocols are restrictive, contradictory in many places, and long (over 300 pages). To avoid getting yourself in trouble, even for things that really are of no consequence, you need to have an encyclopedic knowledge of the protocols. So I'm not really sure I could help. I do have friends who work in what I would call "progressive" systems, but I think the word is pretty subjective. Places that I would consider progressive tend to have a few things in common: competitive hiring, better than average pay, an involved medical director(s), and local protocols. The last thing really seems to set these systems apart. I have yet to see what I would call a "progressive" system, or for that matter happy paramedics, in a state that has restrictive statewide, or even multi-regional, protocols. I have one buddy who works in Colorado. He constantly remarks about the general autonomy of the paramedics, short and sweet protocols, and close interaction with his multiple, yes multiple, medical directors. There is a general expectation that they are A) Qualified paramedics and Educated. The protocols do not dictate every tiny way, shape, or form of when a medication can be used, how to do intubate, etc. There is hands on training, a robust QA program, and a collegial culture. As for what direction EMS is headed I'd see the "Advanced Practice Paramedic" discussion to see a variety of opinions from many well qualified sources. This is a very contentious issue and very young discussion in our profession. It is probably many years away, if it happens at all, but I think the subject is at the very bleeding edge of what's coming.

Anyone who refuses to recognize that the future of EMS is in preventative healthcare, treat and release, referral to alternate destinations, etc lacks vision. It is a matter of time before someone in this country realizes that there is this preexisting universal public tool to screen and filter out unnecessary medical cost: EMS. The real way to decrease health care cost is to stop people from using the service, or at least the most expensive services. Not accounting tricks, not raising the age for Medicare from 65 to 67, and certainly not Ryancare where we pawn one of the most successful social safety nets over to private insurance companies. The fact of the matter is that private insurance premiums have risen, when adjusted for inflation, 700% over the last 40 years compared to 400% for Medicare (spending per beneficiary). When common statistics show that anywhere from 60-80% of admissions to a hospital originate in the 9-1-1 system, someone should be looking at this and saying, "Gee, what could we do to stop this?" Other countries have; many with outstanding results. You're right, the Wake County model is really just a giant PR campaign and feigned way to spend tax payer dollars. It provides essentially the same supervisory or support role (with a twist) popular in many EMS systems around the country. It doesn't have nearly the teeth to make an appreciable dent, but it has attracted the attention of people around the country. A generation of U.S. paramedics is growing up to learn about a concept that has otherwise been successful elsewhere. Really, the U.S. needs to look to the U.K and South Africa where the Emergency Care Practitioner program is being lauded as largely successful. These programs are looking to expand the roles of these providers given the preliminary results in the communities they serve. Movements like the one in Wake, and the Community Paramedic initiative, should be commended in what they've done and are doing to lead the field into the future. There is no reason why, given the proper education and very small leaps in technology, that a well trained ECP could not treat and discharge a vast majority of the lower level complaints seen by the 9-1-1 system. Create a market and someone will scale down and democratize the basic diagnostic tools needed. X-Rays, basic lab work, etc. No one is going to create a portable X-Ray machine that can be used in the field without a market when they can produce a larger, less complex product with higher margins. Look at the research into metmaterials. What about the research into holographic recognition of bacteria? These are all developments that could bring a level of diagnostic capabilities to the field. I don't think anyone is saying that paramedics should be discharging chest pain patients, but what about the basic diabetic, the COPDer or kid with asthma who responds well to a single breathing treatment and/or steroids? What if these providers could provide daily checks on the noncompliant diabetic? I have patients routinely who ask, "Can't you just give me the medicine. Why do I have to go to the hospital?" I think the reality is that we like to overcomplicate some limited aspects of medicine. We look for complicated answers when simpler ones may exist. Even if at the end of the day we say, "Hey this is a nurses job" I think I'd be ok with that, so long as we insist those nurses intervene at the point of contact to stop wasteful spending. Providing immediate lifesaving care will always be part of our job, but stopping it from happening is the future. We need to insist that our profession be more than a glorified taxi cab. Paramedics need to get a basic college education. We need to insist as a profession that a 4% national cardiac arrest survival rate is unacceptable. If we want the public to place trust in us and invest billions (yes,billions) into an actual robust EMS system capable of the things above, then we need to provide more than a college try on cardiac arrests by supporting, or even putting forth our own, research into how better save people from SCA. Even if that answer is better public education, then we should be the ones out doing it! We should insist on progressive protocols that allow us to provide appreciable changes to our patients before arrival in the ED. We should insist that we are a health care organization separate and unique from fire suppression. My $0.02.

Big news, especially when it comes to parsing through future qualified medical directors. Very good news.

More in Pennsylvania is messed up besides EMS. Everything is pretty much locally controlled. No economies of scale to provide adequate services. With the exception of a few large municipalities, most Pennsylvanians live in rural "Pennsyl-tuckey." Counties provide very few services with the exception of tax assessments, sheriff's departments (typically warrant serving agencies with little law enforcement responsibilities), and jails. Everything else is typically handled by local boroughs, townships, cities, etc. Most basic law originates in local magistrates, who like ALL justices (including their Supreme Court), are elected. The local UPS driver might be your magistrate so long as they take a course... Schools, police, fire, EMS, etc is typically handled by the local jurisdiction. This leads to tons of individual school districts, dinky (sometimes unprofessional) police departments, and borderline, sometimes barely existent fire & EMS. You can also imagine the small town mentality that sets in when locals have access to millions of dollars in tax funds (paid for largely on the backs of property owners- PA has relatively high property taxes-for everything). For EMS this has big disadvantages and now lost advantages. For one, funding is non-existent. It does allow the jurisdictions to have purview over how, and to what extent, they want to provide service. Unfortunately this typically doesn't end up being the advantage it could be. Up until a few years ago, ALS protocols were largely jurisdictional. They're now statewide-something I find a big letdown. This is why so many people who know Pennsylvania had a huge problem with Wang's intubation study. It was done statewide in a state that is VERY rural. ALS is provided by a variety of different delivery models.

I think that EMS should have long ago been defined as a health care profession. Dust is right. True unification is impossible. There is a small contingent of our profession who adamantly opposes any other direction for the profession, and they're right. Those who agree with this vision need to step up to the plate. I feel that it is really going to take two things to make true progress: A) An organization that is well organized by smart, charismatic leaders who can clearly articulate the points we all know to be true. This organization may need to be borderline militant, choosing to directly obstruct and oppose those organizations (IAFF, etc) that choose to keep our profession behind. The central tenant of this organization's advocacy should be around increased education standards. B ) A true leader. I've always seen this person as a prominent, well educated physician/academic who is willing to politic a bit. We have our share of advocates, but no one who has really been willing to challenge the status quo about the future of the profession. We're seeing more and more studies that seem to be diverging on two separate paths: 1) EMS personnel are inherently incapable of doing anything resembling complex medical procedures (intubation, refusing of care) vs. 2) These studies are flawed and performed on biased cohorts (municipal fire systems, rural Pennsylvania-Wang). EMS has really made great strides and could probably play a more prominent healthcare role if providers were properly educated and utilized. Someone needs to step up and push us into higher education and more prominent roles in preventive health and primary, community care. Even still there is professional disagreement among people on the "enlightened" side. I compare myself to Dust, whom despite agreeing with me on virtually every argument regarding higher education, has seemingly always disagreed with my vision of eventual advanced practice. Dust brings up important questions about being good at what we already do, before biting off more challenging endeavors. I argue that higher education will only be mandated once the market, in this case healthcare, sees a reason for anything short of certificate trained, paramedic mill firefighters. Its a good argument to have and I have always appreciated the opportunity to forge my opinions on this essential question. Regardless, someone needs to first step-up to the plate and vehemently disagree with organizations that continue to push us towards the predominantly public safety realm and not healthcare.

My prayers are with them and their families. GOD be with them.

Jwade, You're probably from one of the following: University of Maryland, Baltimore County-UMBC UPitt (my second choice) GW's old program before they cut the clinical portion. Western Carolina-WCU (excellent program. Buddy of mine graduate from here) Eastern Kentucky University of New Mexico University of Southern Alabama University of Texas Health Sciences University Central Washington University Loma Linda University Western Carolina and UMBC bicker back-and-forth about who started the first program, but there is some historical evidence to suggest that UMBC's started in 1980. Founded by the late R Adams Cowley. Both WCU and UMBC have fairly elaborate alumni networks. The above are the only bachelor's programs in the country that aware degrees for clinical purposes. There are other programs that focus on management and healthcare economics. Sort-of disappointed though. The year after I graduated the university made the department lower the entry credit requirements due to too many credits required for graduation. Typically students had to complete almost 150 credits (instead of the typical 120) to finish the program. The university had them remove the chemistry requirement to bring it down to a more manageable course load. Students typically handled a load of at least 15-19 per semester, or took summer and winter classes, to exit within four years prior to the change. The current prerequisite requirements, prior to applying for application to the major at my school, are: Introduction to Biology (6 credits w/ lab) Anatomy and Physiology I & II (8 credits w/ lab) Finite Mathematics OR Completion of College Algebra and Statistics for the Sciences (4 or 8 credits respectively) Introduction to Psychology (4 credits) Introduction to Sociology (3 credits) Abnormal Psychology (3 credits) Introduction to EMS (history class) (3 credits) English Composition (3 credits) 16 Elective Credits. It's my understanding that the department highly encourages competitive applicants to use these to complete at least inorganic or biochemistry prior to application. Prior to my graduation this was a requirement ALONG with 16 elective credits. The school requires a foreign language profiency that eats a lot of those up. Many students choose to add microbiology or other sciences courses. Large subsets of students are premedical or pre-physician assistant so they extend their science education as needed.

Vent, I've obviously struck a chord. You've shown what you really think of the profession in general. You used my "sit in a room" figure of speech as an indication of what I believe nurses do. You talk about the "kid gloves" treatment of paramedic students. You yourself have no idea what you're talking about. Your experiences are from what? Late 80's...early 90's? Do you live in the Deep South or some impoverished area of this country where paramedic education is completed in trailers? Jeez man. Symbiotic and symbolic also have nothing to do with each other. Interesting as symbiosis is a biological term that should be well understood by a nurse. You talk about how paramedics gripe about nursing home patients and how "B.S." the care is in these places. Common Vent. If the pinnacle of nursing education is to ship out patients to conduct borderline Medicare fraud (to readmit after X number of days) or because they've noticed a mild change in mental status, you've got to be kidding me. Most of these nurses couldn't tell you what the patient's normal mental status is (They don't care. Too busy gabbing at the nursing station). Doesn't help that there is a huge influx of non-English speaking, Caribbean nurses because of the artificial nursing shortage. Remove yourself from flight RN/RRT/whatever badge you’ve collected and think about the typical nurse right out of school. Not so many are spectacular. I’ll also say it again: I’m not saying nursing is useless. They’re just not that different than us. All I’ve heard is a bunch of stuff about compassion and “total care” that seems to have come from a Johnson & Johnson nursing commercial. You talk about following patients? What practical skills are you talking about? That a human being, a nurse (they’re super special and empowered with special skills of reason), is capable of realizing that there are multiple facets to healing? Are you implying that paramedics can't feel for another? That we're all cold, heartless idiots? “I’m sorry sir. You’re a traumatic brain injury patient who needs to go to Cat Scan. Unfortunately I’m incapable of finding the room. For that matter sir I have no idea what a Cat Scan is. But why am I talking to you? I probably don’t even realize that you have severe, long lasting neurologic deficits because I’m a stupid paramedic and not an awesome nurse.” “Miss I can’t empty your urine because I’m incapable of understanding the implications of urine output and overall renal function. I’m just a big dumb paramedic.” “Well sir. The doctor finished that in situ pinning. Your femur should be all better now. Here’s five dollars and a cane. Have fun! Oh, what is that? You need physical therapy? Ah, I’m sorry sir. I’m just a paramedic. I thought you’d be all set!”

Still a lot of nothing. Honestly Vent I'm not saying that a paramedic is even remotely qualified to be a nurse-there are obvious differences in roles and responsibilities. I'm saying that the educational deficits seem small to me. You've still failed to give me specific examples of when and where, in the entry level educational process, this occurs. I'm of the opinion that much of it is on-the-job or clinical related. Again, something I believe could be easily integrated into a quality paramedic education. I think your on the defense when I'm more on your side than you see. You seem to advocate compartmentalizing healthcare professions, which I'm not necessarily against. But what I don't agree with is a paramedic being clueless about what happens to their patient once they leave their hands, or not knowing how the continuity of care affects patient outcomes. A well educated paramedic should be capable of sitting in a room and not only understanding the job a nurse performs but vise versa. That isn't how it works in this country. Paramedics are often left out of overall healthcare considerations for exactly this reason. "Oh, those poor things don't know any better." I worked on a hospital floor for almost two years prior to college. Of the over 1200 hours (yes) I did for clinical rotations, at least half or more were in hospital environents (and no not all in the ED). I've been in ICUs, flight environments, progressive care units, PICUs, etc. There were very few instances where I watched a nurse engage in anything that I didn't feel I had a very strong grasp of (w/ neonates and some aspects of LDRP the exceptions). Yes, I learned a lot. But it wasn't fundementals-ussually more procedural. Some of my best education on vents came from nurses. ECMO, IABP, and LVAD orientation was also done by nurses. In fact, the experience was often symbiotic. We didn't fight nor puff our chest at how different the professions were. I distinctly got the impression that we each learned something from the other. In fact, the only place I have ever encountered a nurse who was brazen enough to insult the paramedic profession was in the ED. The rest seemed to genuinely get that the profession had its values and distinct specialities. So, yes I have been there. That is why I'm confident when I assert these questions. Healthcare is no different than any other service. There is a large propensity for fraud and waste. As Chbare said, a lot of it is political. It's creating a need for something from nothing.

Vent, "Unless you have been through the RN or even RT program and have worked in that profession, you may not fully understand what they do or know." I'm still seeing a lot of "you wouldn't understand." I refuse to accept this excuse. Other professions have to justify why they exist and what it is they provide that is valuable. Nutrition? Maybe impliment a nutritionist guidelines, but you seriously want me to believe this? I have never encountered a patient in the hospital environment that didn't have a detailed nutritional plan developed by a registered dietitian for a specific type of patient. Those with specific nutritional needs may have prompted a nurse/dietitian interaction, but that was rare. Speech class? Most of this thread still reeks of a lack of understanding. A speech class? English comp? You think I completed a reputable Bachelor's Degree without these same classes? Decision Making You want me to seriously believe that nurses are empowered solely with the ability to make cost benefit analysis of "quick" vs. "longterm" actions? Common Vent. You're doing exactly what I didn't ask for. I want precise measures of how these things are different in the nursing realm. Again, I consider this protectionism. I'm not saying that paramedics should be nurses, but I am questioning the reported huge differences in scope of understanding. Even the things you address (insulin, nutritional needs) could be addressed by simply rearranging some of the curriculum (at least mine). The base education is there. Where I will agree is that, in general, the paramedic (not EMS) profession is ill equipped to handle these changes on a wide scale basis. Even if it functionally did not change what we do I would welcome an identical scope of education to the nursing profession to abate precisely this argument.

Vent, Good response. I still feel like it comes with a bit of predetermined bias about what is and isn't taught in a good paramedic programs. My patient assessment class was almost 6 months long, Monday-Thursday. The majority of the class was taught by a combination of PAs and physicians. We were taught to do entire assessments of the entire body, not just from an EMS standpoint. There was a realization that many of our graduates may work in industrial settings or overseas. So yes, I do have training in recognizing and classifying ulcers. Yes, I was required to memorize cranial nerve exams (right down to corneal reflexes-cotton ball included). We had individual exams on every major system. I had to know Kehr's sign, Cullen's Sign, Grey Turner's, etc. Normal lab values, etc. I’m just pulling some of the things you mentioned. Respiratory standpoint? Yes, I know and can describe in detail a V:Q mismatch, shunting, partial pressures, anatomical vs. physiologic dead space. Communicating adequately with a patient? Yep. Mental health, including death, dying, and disability, was a major portion of my education. So when you write about these things I get frustrated. I'm not one of those paramedics. As for the DNP, trust me when I say I see the value in a terminal degree (I attended a Carnegie Research Extensive University), but I was writing specifically about the DNP as an entry point to advanced practice. It is my understanding that this is being considered, though not currently required. When will the nursing profession simply come out and say it. They want an entry pathway to independent medical practice separate of traditional medical education.

My prayers are with him and the family.

These programs really are the infancy of what I think will inevitably become a standard career route for paramedics. The reality is that EMS education standards need to increase dramatically. Some political things need to happen too. One of the brightest, and I think future telling, developments I recently saw came from a proposed bill that was shot down in Maryland last year (I know, really). In an attempt to reign in the monopoly that is MSP aviation, a state senator introduced a bill that simultaneously created the first State Board of Paramedics. The bill specifically required that the board serve as a self-regulating professional body that was separate of the nursing and physician boards. Like the state nursing board it required some collaboration, but was mainly self regulating. The bill got shot down by, surprise, the state volunteer firefighting association. I think these things are the two most important steps our profession can take. Become self-regulating and make stringent entry requirements to the profession. Advanced practice would surely follow within a decade. This was a particularly interesting development for Maryland because the state has a well oiled statewide system of EMS oversight that is conveniently close to D.C. It also has the educational resources, including a university program, which could easily pilot some of these proposed programs. Maryland also has diverse demographics, ranging from dense urban environments to vastly rural areas in the east and west. This part of the bill was not well read by most people due to the political hysteria surrounding loosing the vaunted trooper program (ugh). Some observers, especially knowledgeable professionals, were closely watching the development of the state board concept. That particular clause was very well written and researched, to the dismay of certain well entrenched career politicians at MIEMSS. It died in the senate due to extremely heavy lobbying from fire organizations which are in MSP's pocket. BUT it pioneered the concept, at least in Maryland. I look to see it in the future. This is especially as MSP has become increasingly expensive and resistant to meaningful change and oversight. I've heard that it may be introduced again during the next legislative session. EVERY paramedic in the country should write and support these changes.