National Scope of Practice

[toutdoors]

I live and work in a tri-state area. The ALS ambulance service I work part time on provides paramedic assist to the neighboring communities in the bordering two states. All three of these states have different levels of providers. It is confusing. I believe this topic ties directly into another post that was active just a week or two ago in regards to a more professional EMS system.

I don't think it does us, as an EMS population, much good if there are so many different levels of certification in the country. I understand that all one has to do is travel about 30 to 60 minutes in any direction from where they sit, and see some differences in EMS no matter how slight they may be. Now, let's travel to the middle of our neighboring states and see how they operate, could be dramatically different. This is one of the biggest issues that should be addressed. In my humble opinion.

I am sure Dust and Spen will agree that the best way to solve this solution is to just have everyone that wants to be in EMS become medics. I honestly doubt if I will ever see this happen in my lifetime. I don't think that taking blood glucose measurement away from basics is a real smart idea, it is a great assessment tool to utilize. I agree with Dawn, when the comment is made "if grandma can be taught how to stick her finger, don't ya think an EMT B can be taught as well?" Of course, this isn't to say a basic may be able to correct the hypoglycemia if the pt will not tolerate oral glucose, but it at least gives you one more tool to use to evaluate your pt.

I am all for streamlining the levels of providers out there. I was never crazy about the first responder, and I was a first responder for a couple of years. I think the basic, an advanced EMT, and paramedic, then throw in the critical care paramedic for good measure. Can't really see where you need to get a whole lot more diverse than these four levels. Does this mean that folks are gonna have to go get some more training/education? I imagine that may be the case. Then again, a little extra knowledge never hurt anyone.

I am not really all that up on how much influence the national registry has on the individual states, but maybe it is time that the reigns get tightened a little bit. I let my national registry EMT go, and kept my state, simply because I never intended to move from my job. After I get my medic, I will keep the national on that though. If for no other reason, I can have that cool looking nationally registered patch. In all seriousness, I think it is high time that the EMS world stood up for themselves and said that as an orginization, this is how we feel things need to be. A good working relationship with medical directors who are interested in being advocates for EMS to the state and national levels, would also do wonders for all of us.

In short, I think it will be interesting to see how things pan out here in the near and somewhat distant future. Just my meandering thoughts.

[JPINFV]

I don't think that taking blood glucose measurement away from basics is a real smart idea, it is a great assessment tool to utilize. I agree with Dawn, when the comment is made "if grandma can be taught how to stick her finger, don't ya think an EMT B can be taught as well?" Of course, this isn't to say a basic may be able to correct the hypoglycemia if the pt will not tolerate oral glucose, but it at least gives you one more tool to use to evaluate your pt.

1. Well, using a pulse ox is just as easy as sticking a probe on a finger and reading a number, why not let basics do it? Well, determining a AMI is as simple as putting a bunch of patches on and reading a print out (12 lead, machine interp), why not let basics do it? Well, generalized trach care is so simple that a patient can be taught how to do it, why not let basics do it? Where do we draw the procedure/intervention line for providers at a level where the national "standard" (NHTSA) is 110 hours, total, can do?

2. If it doesn't change a providers treatment, why use it? What is an EMT-B going to do different for an unknown ALOC vs a diabetic ALOC?

[toutdoors]

I never mentioned pulse ox, but now that you mention it, several BLS services utilize it. At least around here, I should say. Does it change any of their interventions? Not a whole lot, other than go from a nasal cannula to a non rebreather maybe, this they are capable of. What I meant to say is that although a basic will not administer D50, they will have a measurement of the blood glucose level. Much like a basic isn't going to administer 0.5mg of atropine to a patient with a heart rate of 48 , but they still take a pulse; of course we don't have to poke a finger to do it. Now before everyone gets jumping on the bandwagon, let's remember we don't just shoot some atropine at ya cause you are bradycardic. Let's hook up the monitor to ya, and ensure we are talking a sinus bradycardia. Maybe not the best comparison, but I think you understand what I am saying. Maybe the basic can not perform an intervention that is needed in certain patients, yet they do know what is happening, maybe.

I am not saying that interventions are "So easy a cave man can do it". Rather my intent was that it is merely another way to provide more documentation in regards to assessment. When I am working fire, and we get a blood glucose on a pt, and it is 32, pt has Hx of diabetes along with an altered LOC, and ALS is still en route, I will call them and tell them what we have for V/S. I would like to think that this is streamling pt care in this instance. The medics know that they need the drug box, as they don't always take it in with them on every call. Not bashing them, just stating how it happens is all.

JP, I understand what you are asking in regards to where does the line get drawn? For one thing, maybe the hours need to increase for the basic?

[dougd]

I am not saying that interventions are "So easy a cave man can do it".

Ok, I'll say it then... taking a d-stick is a so easy a caveman can do it. Which is why anyone can walk in to any Walgreen's on a street corner and buy a glucometer. Which is why OH considers it a basic skill. (http://www.ems.ohio.gov/policies/EMS_Guidelines_Procedures07.pdf)

If it doesn't change a providers treatment, why use it? What is an EMT-B going to do different for an unknown ALOC vs a diabetic ALOC?

You're assuming every hypoglycemic patient you encounter is going to be unable to tolerate oral glucose - and while that may often be the case, it isn't always.

[VentMedic]

Ok, I'll say it then... taking a d-stick is a so easy a caveman can do it. Which is why anyone can walk in to any Walgreen's on a street corner and buy a glucometer. Which is why OH considers it a basic skill. (http://www.ems.ohio.gov/policies/EMS_Guidelines_Procedures07.pdf)

Let's clarify a few things concerning the patient and THEIR glucometer. Once a patient is diagnosed with diabetes they don't just go to Walgreens and buy a glucometer. This person will go through several hours of education/training by other medical professionals about their disease, diet, insulin, lifestyle and how to regulate everything accordingly by the use their glucometer. I can assure you, in most cases, the "hours" will add up to many more than an EMT-B will get as an explanation for it. That is because the patient is also doing their own interventions by giving insulin which an EMT-B can not. Don't insult the intelligence of all diabetic patients because for many, this is their life and not just another "skill". Maybe if it was looked at with a different attitude by some as to how it can improve patient care and not "because they can in that state", expanding the EMT-B education would come alittle easier.

[dougd]

Let's clarify a few things concerning the patient and THEIR glucometer. Once a patient is diagnosed with diabetes they don't just go to Walgreens and buy a glucometer. This person will go through several hours of education/training by other medical professionals about their disease, diet, insulin, lifestyle and how to regulate everything accordingly by the use their glucometer. I can assure you, in most cases, the "hours" will add up to many more than an EMT-B will get as an explanation for it. That is because the patient is also doing their own interventions by giving insulin which an EMT-B can not. Don't insult the intelligence of all diabetic patients because for many, this is their life and not just another "skill". Maybe if it was looked at with a different attitude by some as to how it can improve patient care and not "because they can in that state", expanding the EMT-B education would come alittle easier.

*sigh* I'm hardly insulting the intelligence of diabetic patients. I'm fully cognizant that my diabetic patients know more about their disease and how it affects them than I could ever pretend to. The point I'm trying to make, and perhaps I worded that poorly, is the actual act of taking a blood glucose reading via a finger stick is an easy skill to teach and learn. Now then, understanding why it is a good diagnostic tool and can provide some useful information as to what is or is not going on with your patients requires education. I'm all for increasing education in EMS across the board and I certainly don't believe we should just be pushing skills down the chain to EMT-B's for grins and giggles without increasing what we are teaching. I already listed in a previous post on this subject how I believed it could improve patient care:

"On a squad running B/P, it frees the paramedic up to take care of other parts of the assessment and on a BLS squad it at least gives you an idea of what you're dealing with. Sure, if they're down far enough they're going to need a line, but if we can identify and treat our hypoglycemic patients before we have to move to an invasive intervention, I'm all for it. "

[stcommodore]

This is a constant debate, its not an issue of "if" the EMT can do the skill its if there is a strong education background for the provider to understand why. The national standard calls for paramedic education to be a degree based/2 or more year length program but we continue to rush through providers from nothing, bls, to medic as quick as possible.

I support a very basic BLS level, no nitro, no asa, no medications unless assisted medications. 80% of calls are BLS and require little of any care and the basic level is probably the most important level there is.

[VentMedic]

This profession is almost 40 years old and we are still concentrating on expanding the "skills" of the lowest level of certification (or adding more low levels of certification) instead of pushing for the highest level to be recognized as a medical professional. It is about time we concentrate on something that will endure the test of time and not just a "skill" to keep up with the next state. Other professions already discovered this about 2 - 3 decades ago. Many of these professions are much younger than EMS.

Unfortunately, those that focus just on skills don't realize that many other professionals would leave them in the dust if you just added up the "skills". Now add the education they have to back up the skills and you get a "medical professional" and not a patch collector. It seems there are some that want to do a few things but not to where they will have to assume that much responsibility. They want to be "like a Paramedic" but not put the effort into it. It's fine as long as they are just "helping" and don't have to do any real intervention. I find expanding the scope for the EMT-B just another excuse for someone not to do the extra 700 "hours" to get their Paramedic. Piece milling does little for patient care if you are not able to put the assessment puzzle into some logical order.

Edit:

Yes, there is still a need for BLS but there is a greater need to get EMS recognized as a medical profession with some real education.

[reaper]

AMEN Vent!!

[spenac]

National protocol would always be the minimum if it were to work. The medical directors would and should have the right to expand scope of practice based on the needs of their community. Many of the skills that people are griping about basics doing I did and a whole bunch more. I get sick and tired of people taking a one size fits all attitude. Yes if you plan to be in EMS please get paramedic so you get some education to go with the skills. And yes most EMS skills are so easy a basic can do them. No that doesn't mean a basic should do them. You need the education to understand what, why, when etc. If you are basic wanting more skills get your paramedic. Regardless of what level you are at never stop learning. Study, study, study, practice, practice, practice.