Education Standards Gap Analysis Documents

[Ridryder 911]

Here is a link to the Education Standards Gap Analysis Documents, which is the study for developing bridge courses according to the new levels. Developing educational standards to those standards that is currently used at this time, in other words education vs. training.

http://www.nasemso.org/EMSEducationImpleme...t.asp#GAT071709

[Kaisu]

Great stuff Rid. I will check it out in detail after I have shaken the cobwebs out of my brain. Thank you for posting.

One question - what are the chances that the role of prehospital health care will someday involve a triage type situation where paramedics can be the front line in the allocation of health care resources - ie. sometimes referring patients to their own physicians, mental health clinics, etc. as opposed to the current transport them all to the ER?

I realize this requires a LOT more education before we can expand the scope of pre-hospital medicine. I am very interested in your thoughts.

[Ridryder 911]

I see two options but it is determined who really gets involved into promoting EMS. If the insurance and healthcare administrators were wise, they would mandate and force EMS to become a true recognized health care profession (academic and degree entry level). With our diversity, and background we will make great "screeners" as the move towards the "health care for everyone" becomes not just a popular but demanded stand.

With this and the current number of baby boomers, the industry cannot meet the demands that will be placed upon the number and level of providers we have now. We may debate day by day tasks on EMS forums, but it is a rarity we discuss the truth of what the demands of health care will be like within 5, 10, 15 years. Just the aging population alone is factual enough to demonstrate that the number of hospital beds versus the ratio of patients will not be met. Hence, EMS will have no choice but to be a filter of whom and when and if one will get to go to an ER.

Of course, we could not expect those graduates of the current curriculum and scope are adequately educated enough in performing what we now call a medical screening evaluation (MSE) which is (should be) performed at every ED. The advancement of detailed assessment would have to be greatly increased and of course correspondence education and advanced skill levels.

At the same time, it will not be necessary for all of those in EMS to be able to perform this clearance but as soon as the patient is stabilized I do predict such advanced level practitioners will have the authorization to perform this task and thus reducing needless hospital visits.

Many may laugh, or describe that physicians will not want to be responsible or the pay structure will not be enough to sustain such levels. I do believe though, the savings will be enormous and those that have the fortitude to go to higher education level can and will be compensated appropriately. Insurance corporations have been attempting for years to prompt us into advancing our profession but we still resist progression. Unfortunately, as I always describe if we don't do it; they will develop or find someone else that will. It's our choice.

R/r 911

[Kiwiology]

I am no expert on the American legislative or health system (except for those couple hours I was spaced off the planet at the ER in San Diego ) and have seen some very good, very progressive systems firsthand (e.g. Boston, some third-service providers in Florida, EMSA in Tulsa (I have family there), Medic One (if we take out shady cardiac arrest numbers) and have thoroughly kept an interested eye on the national EMS agenda for the future I must say it angers me reading these documents!

While our system here is not perfect (far from it) I will draw the following broad comparisons and conclusions based upon the EMS agenda for the future documents and the gap analysis ....

- No talk of shifting away from the "working under a physicians license" model to practicing under individual licensure like in the UK, Canada and South Africa (being considered here and in Australia too)

- Limited discussion of moving towards a nationally consistant, Federally regulated education model (a mandatory cirricula overseen and audited not by the state, but by the Federal government. One standard for all not a standard that the States can pick-to-death!)

- EMTs still won't be able to administer inhailed pain relief, nebulized b-agonist, intramuscular glucagon or insert supraglotitic airways like the King or LMA (things our basic AOs can do here)

- No blood glucose monitoring at EMT level (I suppose wo ability to administer glucagon there's no point really)

- Advanced EMT has had cardiac monitoring (even if it is just Lead II) taken away

- Advanced EMT is not able to manually defibrillate

- Advanced EMT's ability to administer adrenaline is only for anaphylaxis, not status asthmaticus

- The ability of the State to change and pick-to-death makes me curious as to how much of this sytem will be adopted

- The educational content in relation to anatomy, physiology, pharmacology and pathophysiology is concerning as it still seems rather inadequate

- No talk of Paramedic education being transitioned to a University system (which is increasingly internationally inconstent)

- There still seems to be too much focus on "emergency" and "critical" patients only and not a balanced shift towards a broad knowledgebase about all patients be they emergent, urgent or low acuity.

I know it's like comparing apples to oranges but let me give you a run-down on our "basic" and "intermediary" providers can do and what they need to do to achieve it because really that's where the greater benefit I think will be; not from Flash and Whizbang the Paramedics on the streets of any major city with 2 hospitals five minutes down the road but from Joe and Frank the volunteer EMTs and Sally the Advanced EMT out in Prarie Flats, Mo. pop. 347 when they are recalled to duty at 3am for ole' Mrs. Sample having a cardiac event and is an hour from the hospital on country backroads.

Note that we are slowly transitioning away from this model of education listed below towards a university level degree (which is now required for all staff who want to make Advanced Paramedic (ALS)) and the majority of new staff have this degree which is on-par with the BScN (RN) program, very comprehensive university level education. I've done the A&P ahd pharmacology components of this degree and have been very impressed as the content has come from the bachelors level nursing programs.

- Our BLS providers have to complete 14 weeks of "book" learning covering core skills, trauma and medical including A&P form & function (mainly at a system level although cardiac and resp go into a very good aamount of detail including ECG), pharmacology, core skills, medical and trauma. They then complete 21 days in class covering all the practical skills (this portion of the course amounts to 147 hours in class and around (averaging 1.5hrs on the 14 week theory component for every 1hr spent in class) 220 hours of self-directed learning). Once this is completed an Officer must compile 20 calls (patient condition, signs and sympotms, treatment and rationale etc) and go through an exit assssment with a Clinical Standards person.

- This process (called the National Diploma in Ambulance Practice) allows the officer to autonomusly administer GTN, nebulized salbutamol, aspirin, tylenol, entonox/methoxyflurane, glucagon PO/IM, insert OPA, NPA and LMA (laryngeal mask airway), acquire a 3 lead ECG and measure a BGL. They can also assist with (by standing order) patients rx'd midazolam (or other anti-seizure medication) and adrenaline (Epipen) although there is talk of adding autoinjector adrenaline to thier scope.

- Our ILS providers must complete 10 pre-class assignments (4 cardiac, 2 shock/fluids/IV and 4 drugs) which go into a comprehensive amount of detail about cardiac A&P, ECG rhythms, cardiac electrophysiology, pathophysiology of shock, fluid compartmentilization/tonicity/osmolarity etc (the drug assignments I have not seen) which probably totals .... 100-200 hours of study and complete 140 hours in practical class and hospital settings. During the in hospital and on road sessions you must demonstrate competence at identifying and acquiring 30 rhythm strips (no, 30 of the same kind don't count! lol), performing 50 IV starts and on-road pushing a certian number of drugs.

- This process allows you to acquire a 12 lead ECG, interpret a 3 lead ECG, manually defibrillate and cardiovert, start IVs including an EJ and administer IV NS, 10% glucose, adrenaline, metaclopramide, naloxone and morphine. There is talk of adding amiodarone IV for cardiac arrest to this level.

[Ridryder 911]

I agree our system might have started the ball rolling but definitely dropped it. What appears we have and you don't have is the stark opposition in progress. For example one of the cities such as Tulsa is coming under scrutiny and the push of moving EMS into the FD, even though there had been re-registration procedures that had been found out to fraudulent. Even its sister city in OKC the push alike so many is to guarantee FTE for the Fire Service.

Then the ugly head of many of the volunteer systems arises and protests against increased education and push for lobbying against formal education. Unfortunately, it is not always the rural as you have described but those cities that could afford and provide 24/7 Paramedic ALS level care but due to "tradition" and being cheap and ignorant refuses to.

Who would have thought after 40+ years, that we would still have "first aid" units and worse boast about it?

Yes, we could learn a lot from other systems. Truthfully, we already know what we should do... rather what we cannot do is what makes it frustrating. Those two main groups have very powerful lobbying and active participants, sadly more so than those that acclaim that they want good care for patients in the U.S.

R/r 911

Edited July 21, 2009 by Ridryder 911

[UMSTUDENT]

I think the inevitable change from a transport model to advanced practice, in-field triaging of care and treatment will come at the request of either A) Government B)Insurance Companies or C)Academic public health and emergency medicine experts.

This is sad, because we as a profession are paralyzed by so many competing lobbies. The issue of EMS Advanced Practice is a purely (almost) political one. At this point in 2009 there is plenty of evidence, both anecdotally and from actual trials/active programs, to show that a well educated, independently practicing paramedic can inflict huge cost savings on the health care system. I read recently that the Nova Scotia Community Health Paramedic trials have, in some cases, produced a 40% drop in ED admissions.

Add to the above problem a generation of currently practicing paramedics who obtained their training through the simplest means possible (certificate programs) and you rapidly see the aversion to "higher education." The key will be to develop adequate bridge programs to bring most current paramedics up to speed. Make education accessible through an industry sponsored campaign. Make it necessary for current employers to make education a priority and develop funding options to assist with that education. I guarantee if Medicare or the insurance companies said that they wouldn't pay out claims to paramedics w/o associates degree you'd see a massive national push to make formal higher education a priority-overnight. More likely, you'll just see a decrease in certificate paramedics through years of future attrition (unfortunately). Once the NREMT and other organizations get the gumption to end certification w/o formal education you'll slowly see older paramedics get on board, retire, or be priced out of the market as their higher educated peers advance in leaps and bounds (as in nursing now).

Very simply: A master's trained practitioner with some degree of independent practice with limited physician oversight. Require all paramedics to license at a minimum of an associate's degree. Critical care or paramedic supervisors should be obtaining Bachelor's level education. Similar to nursing. This is an issue that I take seriously. I know many paramedics whose years of experience have made them excellent providers. I know people who were priced out of education or grew up in locations where the idea of getting a degree to work in a fire department was just ludicrous. These people need an option. The critical problem is for our profession to buck up, establish new standards, and then come up with innovative solutions to bring the rest up to speed.

Every single paramedic should be shouting from the hilltops. "Education!" - "Higher Pay" - "Advanced Practice." Every paramedic should spend some personal thinking time with the possibility of a well respected, self regulated profession. They should seriously think about what that means and how badly we deserve it. It doesn't happen by being complacent or accepting the status quo.

Edited September 28, 2009 by UMSTUDENT