Is There a Need for the Advanced Practice Paramedic?

[Arizonaffcep]

In reading the Wake County link and reading the other posts, etc. It sounds like a good use for the the APP would be as a mentor for new medics. Put new medics with the most senior medics and use it that way as a career ladder. Not to say the APP would have any different "abilities" so to speak, but can help the new medic gain confidence, skill base, etc. The only problem I would see for this is, at least in AZ, new medics are only 3rd person on the box for a short while, then turned loose on their own. I would think if you have them as 3rd person for at least 100 shifts (average 10 shifts/month) this would really help to boost the quality of care all the way around.

[Niftymedi911]

Wow, I must of not really read it through enough last night until now........ I simply cannot help but think..... do the medics in the field now really want this? Accorrding to Wake's PP, they're taking the intubation, the advanced pharmacology, and the more advanced and infrequent skills and placing them under the APP. For one thing, if they're rarely used as it is (infrequen skills) how the heck will the APP be able to perform better then a road medic? And if you say well better training.... well why not provide the better training and QA/QI training necessary to maintain those skills to your entire department.... instead of re-inventing the wheel, removing certain items off the trucks, and placing them under a new job classification? (oh your kidding me, that would just make toooooooo much sense) It's funny how everything comes back to education aint it? I simply can't help but feel they're "progressive" medical director can't trust a road medic to accomplish their task, when placed under pressure to perform. It's more of a CYA thing then anything else. And if your going to degrade the skill set of a Paramedic because you don't trust them and placed them under an APP, why bother having "regular" medics? Mentorship, smentorship...... it's smoke and mirrors.

Example:

You respond unknown distress, upon scene secure you find a 48 y/o/m not awake with agonal respirations, posteuring, and an intact gag reflex. You notice multiple blunt force tramua areas to the head and neck and you obiviously need to be able to intubate the patient. <10 min on scene time and you really need to be able to perform the skills enroute. But in a case like this, your APP with RSI capabilities is 14 minutes out and your approx 12 min from the trauma center. How good is that APP program working for you now??? What benefits will this patient have, now that the APP is the only one who is able to DAI/RSI?? Didly squat, because you only had a BLS airway and during transport he aspirates because he starts vomiting...... yea, ummm no I'm not living in Wake County anytime soon.

In my book any program that has loop holes where majority of the patient's that fall through the cracks end up having a negative outcome, are nothing but a ticking time bomb.

APP's have their place like as outlined in MD's and Urgent care centers, but not in EMS.

UM, I was not attacking your credentials so please don't take offense. A mere generalization was used to shine a light on the subject. There are numerous people who have extensive amounts of training and experience. But, on the flip side there are also an extremely large amount of people who have "Joe the plumbers" medic mill certificate that have no formal education. Which is where I was trying to address.

[Mateo_1387]

The way I am understand the Wake Co. APP program (from my limited knowledge gained from friends within the organization) is the APP is to in essence bring experience to the critical patients and non critical patients who do not require transport. Wake Co. is finding that patient outcomes are better when handled by experienced paramedics.

Wake Co. like many other places are short of paramedics, they are having to resort to placing medics with intermediates/basics. I do not think they are diluting the paramedic population. These paramedics arrive on the most critical calls and provide an extra hand, as well as experience. The medic on the ambulance is still involved with the patient care.

The idea of making the paramedic a poor man's PA is not the idea of Wake Co, at least this is not what I am seeing. For emergency calls that are what we call "BS" because they do not have a life and death emergency are transported, and given simple treatment at the ER. This program is still treating emergency patients, or providing the reference to the proper medical professional. The program design is to take unnecessary stress off the EMS system and ER when care by each is not necessary. Care may be necessary, but an ER evaluation may not. The APP will also be involved in complex cases that need a Paramedic with experience to make the necessary judgement call, such as if a patient requires transport or not.

The idea of placing the critical interventions into the hands of the APP is to not necessarily take them away from the regular road crew, but to have the APP more proficient in the skills. For example, we all know that in order to be proficient at intubations it has to be practiced/performed frequently. The APP should see and perform more intubations because they are sent to the most critical calls. On these calls, the patient gets an experienced medic, and so does the regular road medic. The APP can help guide the road medic to performing critical interventions to make the road medic a better medic. The idea is not to take away skills, but to provide better care for the patients by experienced paramedics.

[zippyRN]

advanced practice paramedics will not happen in the USA until the education required to become a paramedic at least approaches that required to become any other flavour of health professional.

billing will also be an issue especially with the active exclusionary policies in place in the USA towards skill development

[spenac]

I like the idea of being able to treat and release rather than transport.

Why not treat and aminister enough meds to get them to the next business day to follow up with their regular doctor?

I think this will lead to higher education required. Higher pay for added responsibilty. A cut back on transports, making ambulances more quicly back in service for real emergencys.

Regardless of how its set up we must have the right to deny transport to those that are non emergent. If you do not have enough education and common sense to determine if it is a true emergency you need to get out of my profession.

[Dustdevil]

advanced practice paramedics will not happen in the USA until the education required to become a paramedic at least approaches that required to become any other flavour of health professional.

billing will also be an issue especially with the active exclusionary policies in place in the USA towards skill development

Zip, apparently you didn't bother to read the links. What you are saying has no relevance to this discussion.

[UMSTUDENT]

I agree with everyone regarding one short fall of the Wake County experiment.

I think providing a paramedic with advanced intubation skills is probably a bad idea. If every time you, as a "regular" paramedic, try to intubate and some guy or gal shows up and steals it, how will you ever develop a skill level?

If Wake only means to provide a chase car-based paramedic with some experience, I'd be disappointed. My system already does this: we call them EMS Lieutenants/EMS Supervisors. Furthermore the idea of being in a chase car/SUV looses its luster if you're like me and the paramedics I work with and your entire system is designed that way.

[firedoc5]

I hate to be a party pooper, but I'm just going to give a quick short answer from what experience I have had to do with it.

Back in early '88 our system did a somewhat pilot program on this. There were 10 or 12 of us that participated. Overall it seemed to do pretty good. It took a lot of pressure off the hospital in finding nurses for Interstate transfers and other duties. One big notice was that when on calls all we had to do was notify which Medic(s) was on the call and to ask to go by protocols. That relieved them from having to stand by right at the radio for every transmission.

It did cause some discord between a few of the Medics, especially those not chosen to be one of the select few, which would be natural. But the biggest down side was as the original Medics left, moved on, etc. either no one wanted to take their place or there wasn't enough "qualified"to fill their shoes. I know it got down to just four of us and after two years they just dropped the program. We were spent, burned out, tired, etc.

So, I'm not for or against it. It you try it and it works GREAT, but if it causes problems that just don't seem worth it....well, just think of what might have been.

[Mateo_1387]

I agree with everyone regarding one short fall of the Wake County experiment.

I think providing a paramedic with advanced intubation skills is probably a bad idea. If every time you, as a "regular" paramedic, try to intubate and some guy or gal shows up and steals it, how will you ever develop a skill level?

I thought of this problem too. I am sure it is bound to happen. But, again, the way it is being talked, it seems that a paramedic will be there to help guide and or perform if necessary, the advanced procedure. I would not be surprised if they just end up putting it in the hands of the APP's, but who knows?

[VentMedic]

Generally, I am not a proponent of either role. Every paramedic should be educated to the level that Wake County proposes. And we have no business involving EMS in home health functions like oxygen delivery, medical and social referrals, and vaccinations. Apparently, the idiot who designed the Wake County model forgot to take his own advice, which is to not dilute the paramedic's role and experience, because that is exactly what he is proposing. If we start trying to be all things to all people, we dilute our core strength. Do one thing and do it well. If it is not an emergency, then it is none of our business. Without E, there is no EMS.

Once against EMS is behind in investigating what other professions have already discovered when it comes to providing these services. The minimal standards for the specialties of anywhere from a 2 year to a 6 year degree is rarely enough in our complex medical systems. Even Respiratory Therapy is now going with 4 year degree for homecare and that has legislation to reimburse at that level. And, that is just for one specialty in homecare. Social Workers and Case Managers all have recognized this and you would be lucky to find any for this specialty with less than a masters degree, many with the RN as a base. The Paramedic is still at what level of education? 500 - 1100 hours?

I believe it was Lee County EMS that attempted the public health model a few years ago and that did not get a good reception from the Paramedics. Remember, many people did get into this profession for the L/S and trauma stuff, not clinic work.

It is also very difficult to compare our medical system with any other country. In case no one noticed, our medical system is just BROKEN. Our patients are coming to us sicker and sicker with the costs rising to maintain them. If we give them more excuses to not visit a doctor or hospital to where more potential or existing problems can be identified, we are just adding to the declining health issues. Even a 2 year Paramedic degree does not prepare one for that level of diagnostics. PAs and NPs have eased the burden of some clinics' physicians but they are allowed by their scope of practice to order advanced diagnostics and prescribe medicine outside of the emergency situation. The base education for the Paramedic (and the U.K. model also uses a nurse) in other countries is also already established at a much higher level so it makes any additional higher levels more realistic. U.S. Paramedics also are specialized in treating very acute situations and have little knowledge or experience with other things that go into understanding long term diseases, those other "vitals" or even many of the "med-surg" type meds that are usually thought of as BS to a prehospital provider. So some knowledge and even the way of approaching an assessment would have to be relearned. Other countries may already have integrated of this into their Paramedic education.

As far as advanced skills, we already have this in many systems that utilize EMS helicopters. Often they will come to the aide of a ground crew if needed to perform RSI or other interventions but with transport by them being the ultimate. Since many of these helicopters are also involved in interfacility transport, they can do advanced stabilization. However, many of these helicopters also have an RN with several years of Critical Care experience and usually no less than a BSN. But, the concept is still there. I just can not see the situation as described in Wake County being practical time wise or valid use of resources.

I will note that there are exceptions to some HEMS. If they are fire based, it is often with Paramedics that have the same skills as the ground Paramedics. There are also a few services that have a pilot fly out with the helicopter and pick up a medic from the ground crew to go with the helicopter. So that again brings us to the FD issue and with their prevalence in controling EMS in many regions. Higher education with advanced skills will not always be a popular idea. As recently stated on one thread, CPAP and the 12-lead EKG are viewed as "progressive" in one FD.