Advanced Practice Paramedic

[Dustdevil]

I can't speak for Dust but I believe he would answer this question with a resounding yes. At the very least, he has answered the same question previously with a resounding yes.

I agree with him, too. What you're describing in your question is NOT emergency medical services. It's transport medicine. They're not the same.

Agreed. To say that driving a non-emergency ambulance is "EMS" is like saying driving a drinking water delivery truck is being a fireman. Similar tools, but completely different vocations, which should not be confused.

Which takes me, again, back to education. Fix paramedic education and everything else will fall into place. But if you're looking for home health care follow up then I think that would be better handled by nurses.

I agree that this is more of a VNA type function than an EMS function. That said, I can certainly see the value of the programme, in that it mines a wealth of information for system QA and indeed fosters good "customer service" with the community. My two main problems are:

1. The name. It suggests something advanced about the medic's education or scope. It's not advanced. It's just different.

2. The possibility of this programme taking resources from an already over-stretched system.

[tniuqs]

='NYCEMS9115' timestamp='1306807687' post='259725']

In 2000, Lenox Hill used Paramedics in the ER as Triage. This Pilot Program didn't work well. The RN made a big issue and the Paramedics were no longer doing Triage after a year long project.

That is the problem with expanding the Role of the Paramedic. Other Healthcare Providers will intervene in this progression if it steps on their toes.

Why aren't the Paramedics protesting Nurses on our "Rigs" and "Birds"?

EMS is not Medicine or Healthcare in the eyes of laypersons and many Practitioners. It is our (EMS as a whole) fault. We do not petition, advocate, or educate our existence to people who are unaware we exist. HOLD URINE HORSES there are those that write letters and push the envelope every opportunity afforded. This APP may not work in areas where VNA and VNS are relevant. EMS folks crack fun at Nurses but look how far they've progress and look how far we've gotten. Nurses has this voice that demands to be heard. They will wreck havoc if they are not heard. EMS must mirror the Progressions of Nursing... Of course these are my feelings and having others agree is not reason for the post...

Edited May 31, 2011 by tniuqs

[Bieber]

All right. I've held off on posting in this thread because, as usual, this is gonna be a big one.

I've said it before, and I'll say it again, guys. We are NOT that good at managing emergencies, and very little of what we do has been shown to actually make a difference in an emergency. So exactly WHY are we limiting ourselves to solely emergency care? Let me ask you all this, exactly what do you think we're going to do when our local governing bodies figure out that paramedics really aren't as vital as we like to think, but we're in a tight budget situation? Do you really think that they're going to keep paying for anything or anyone that hasn't proven themselves invaluable and non-expendable? The medical environment we find ourselves in is this: if you want us to pay up, you better show up with something more than emotional pleas about how important you are. And we in EMS are NOT prepared to respond to that kind of scrutiny.

We absolutely HAVE to start showing more for our cost than an IV, O2, monitor and transport. Uh uh. That's not cutting it anymore. Every single person here needs to take a hard look in the mirror and ask themselves, "What am I doing that is changing this patient's outcome?" You may be surprised by the answer, and even if you're not if you're not thinking beyond emergencies you're already up the creek without a paddle. Transport to the ER isn't cutting it, so we have got to start doing more than providing little more than that. We have got to start adamantly advocating for higher educational standards, and more definitive (or perhaps conclusive is a better term) care options. We've got to start performing sound triage, treat-and-release, release-and-refer, and offering more than what we are right now.

Emergency medical services is a flop. It's a failure, doomed from its inception. If you want to go down that path, if you want us to just take people to the hospital, you're going to soon find that that's all we're EVER going to be paid for. We can't do that anymore. It's time to step up, own our own education, put on our big boy pants, and start providing true mobile health services. That doesn't mean everybody needs to go to the ER, and that also means that we have got to take a hard look at what the socioeconomic environment of our communities is.

A lot of you bring home up health nursing and how it's not our area and it shouldn't be because that field belongs to the home health nurses. You know what? Home health nurses exist, that's true, but how many patients with chronic care issues that need chronic care treatments do YOU run on a yearly basis? Quite a few, I'm guessing. So what does that say about the effectiveness and reach of home health nursing practitioners? It says that while they may be out there, and they may be doing their jobs just fine, there's still a gap that needs filling. And that gap is one that we as paramedics can fill if we will just get our heads out of our asses and put the rulers away for one second.

I didn't become a paramedic to run emergency calls. And I didn't become a paramedic to only handle the worst of the worst. I became a paramedic because I wanted to make a difference in people's lives, and I wanted to provide vital, necessary medical care to folks. And you know what I found out? Just doing the emergency stuff, I'm not all that great at doing what I set out to. But you know what? I'm willing to learn, I'm willing to educate myself so that I CAN do more for those patients that don't need emergency care.

I am sick to death of transporting so many patients that I can't do a damn thing for. They're sick enough to need medical care, but not sick enough to need anything in my drug box. And that's the majority of my patients. The majority of my patients, and I suspect the majority of your patients, need more than what we can offer them, but what they need isn't emergency care. I know this. You know this. And sooner or later, the politicians are going to realize this and start asking what the hell they're funding us for when we're undertrained and unwilling to handle these kinds of medical situations. Nurses aren't. Nurses are trained to handle these kinds of patients, AND they're willing to do so. And in the time it takes us just to revise our educational standards, nurses could have a system of RN-based mobile health services in place that turns a profit AND provides better medical care than we could ever provide.

We're an odd bunch, we paramedics. We fight when we ought to listen, listen when we ought to fight. But I'm telling you, like I have so many times so far that I fear I'm becoming redundant, that if we don't adapt and overcome; if we don't change the way we operate from the ground up; if we don't give up these notions that increased education isn't going to make a difference to our wallets, and that "we're emergency medical services so we're only going to handle emergencies", we are going to fail. Not today, not tomorrow, probably not even five years down the line. But we will fail, and we will be replaced by people who are smart enough to know that medicine is fluid and to be in medicine you have to be fluid as well. Business as usual isn't cutting it anymore.

So in conclusion, I support Wake County's APP program. I support the NHS' ECP program. Wake County isn't a college, they can't create a Bachelor's degree for APP's, but they're on the right track. They see what lies down the road and they're securing their own position in the future by looking beyond emergencies. I hope that we as a profession will advance our educational standards to meet the need we're seeing, and that in the future the paramedic practitioner will be a Bachelor's degree or higher. Until then, all I can do is take my hat of to those who are doing as much as they can to provide within their means and adapt to the changing medical environment.

Edited May 31, 2011 by Bieber

[UMSTUDENT]

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.

Edited June 14, 2011 by UMSTUDENT