Provider Levels (Controversial Discussion)

[Bieber]

No one payed to reeducate blacksmiths or typewriter repairmen.

Stay up with the times or move on. If you want to continue to work in EMS you have to be useful. The basic level is dangerously close to obsolescence. Tell us where the current level EMT-Basic really helps.

Driving, lifting, vitals, setting up IV's, ventilations, CPR, history taking, hemorrhage control, splinting, wound care, suction, applying ECG electrodes, carrying equipment, history taking, blood glucose level acquisition, supraglottic airway placement, etc, etc.

That may not seem like much, but those are all things that free paramedics up to perform invasive procedures, conduct an assessment, etc. And I'm not saying that EMT education doesn't need a major overhaul, but I'm saying, we've got to be careful that we're not just adding to their skills, because in all honesty we don't want too many people in the system who will be competing for IV's, tubes, chest decompression, and all those other advanced skills that take practice and repetition to remain proficient in. I would say that in a system with only two levels of providers (basics and advanced), we want to increase EMT education more than anything, and maybe throw IV skills in there as well. That's just me, though.

Addendum: I guess what I'm getting at is that I don't think we have a skills deficit in EMS, if anything I think we're moving towards skills oversaturation. What we have, more than anything, is an education deficit--and it's certainly not limited to EMT's.

[Just Plain Ruff]

im not arguing the point that it hurts or helps but who will pay for it when training budgets are already stretched to the breaking point. Its fine and dandy for us who are already medics to say move on or get out of the way but what if the current medic was now obsolete and all the medics were told to either get the new cert or get out of the way. I would bet that you would be singing a different toon.

Could your agency afford to educate or send all your medics to the next level or can your agency afford to send all of your emts to the medic level based on the mandate proposed by the OP? Ill bet that most agencies cannot afford to send their people to enough ceus to keep their licences current let alone put them back through school to get to the medic level.

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[usalsfyre]

im not arguing the point that it hurts or helps but who will pay for it when training budgets are already stretched to the breaking point. Its fine and dandy for us who are already medics to say move on or get out of the way but what if the current medic was now obsolete and all the medics were told to either get the new cert or get out of the way. I would bet that you would be singing a different toon.

Could your agency afford to educate or send all your medics to the next level or can your agency afford to send all of your emts to the medic level based on the mandate proposed by the OP? Ill bet that most agencies cannot afford to send their people to enough ceus to keep their licences current let alone put them back through school to get to the medic level.

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If the current level of medic was obsolete (and it's not far behind) it would be up to me to get the needed education. That's a "tune" I will sing consistently.

[Just Plain Ruff]

but thats just you, what will happen which will make this a nonstarter will be the fire services and unions which will fight this tooth and nail to keep this from happening unless there is some significant financial incentives to make it financially painless for their members.

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[Kiwiology]

There are those communities where it will never be financially viable to employ full time paid Paramedics (or whatever single super level person is invented) because their workload will be extremely low. You need some sort of reasonable alternate to spending years at University for these people. I think New Zealand has it about right in that we put volunteers through a one year course along the lines of the old vocational model which is now obsolete for the higher levels, blocks of time in the classroom and blocks of time on the road until they get all the Diploma requirements finished.

There is a sensible scope of practice associated with this level i.e. LMA, tourniquet, aspirin, GTN, salbutamol, glucagon, oral ondansetron and loratadine, paracetamol, entonox etc

Something like this should be preserved for the volunteers as a reasonable alternate

[EMS Aficionado]

There has been very good debate so far! I am going to push the envelope a little further; hopefully without causing too many hurt feelings.

BLS is non-invasive care that could, and hopefully in an emergency would, be performed by anyone that is properly trained. It is a set of skills should be possessed by firefighters, law enforcement, school teachers, and every licensed healthcare provider. But, does it really meet the requirements of an organized ambulance service response?

It would be unheard of (by US standards) to have an emergency department without a cardiac monitor and someone capable of interpreting the results. Even in the most rural parts of the country, that is the expected standard of care. Shouldn't ambulance care be at the same level as an emergency department? In many places it is. So how can we justify that in some places it isn't?

I acknowledge that some places are very rural and resources extremely limited. Resource scarcity equals longer response times. An ambulance can always come from somewhere, its just a matter of the time involved. Please forgive my coldheartedness, but living an hour or more away from a population center, or even just a community hospital, puts you in a certain category of risk. If anything, the more rural the location of response, the greater the need for a higher level of EMS provider.

Let me propose this scenario: An on-duty police officer that is certified as an EMT arrives on the scene of a medical emergency. In his patrol car he has an AED, a face mask for ventilations, and a small kit with some bandages. A BLS ambulance staffed with two certified EMTs arrives at the same time. The patient has a very low blood pressure. It is because of an SVT. No one knows this because no one there has a cardiac monitor. Even if there was a monitor there, none of the three is capable of interpreting ECGs. In this scenario, we have three individuals certified to respond to medical emergencies and none of them can adequately treat the current problem. If this had been a life-threatening event, such as cardiac arrest, choking, or major bleeding, then the police officer could have provided an equal level of care to that of the ambulance crew.

To my knowledge there is no other licensed healthcare provider (in the US) with less education or training than in EMS (in the US). How can we hope for anything more when we expect so little of ourselves?

[Kiwiology]

You raise a good point, which is why "BLS" by American standards is well, only found in the US and elsewhere a person of such capability of an American EMT either does not exist or is limited to a "First Responder" type deal e.g. Firefighters

We have "First Responders" who can give oxygen, glucose for hypoglycaemia (they can also check a blood sugar) and aspirin for suspected myocardial ischaemia, exactly all the same an EMT under the new EMS Agenda for the Future can do. They have 16 hours of training and are not allowed to crew an ambulance nor transport a patient.

[BillKaneEMT]

There has been very good debate so far! I am going to push the envelope a little further; hopefully without causing too many hurt feelings.

BLS is non-invasive care that could, and hopefully in an emergency would, be performed by anyone that is properly trained. It is a set of skills should be possessed by firefighters, law enforcement, school teachers, and every licensed healthcare provider. But, does it really meet the requirements of an organized ambulance service response?

It would be unheard of (by US standards) to have an emergency department without a cardiac monitor and someone capable of interpreting the results. Even in the most rural parts of the country, that is the expected standard of care. Shouldn't ambulance care be at the same level as an emergency department? In many places it is. So how can we justify that in some places it isn't?

I acknowledge that some places are very rural and resources extremely limited. Resource scarcity equals longer response times. An ambulance can always come from somewhere, its just a matter of the time involved. Please forgive my coldheartedness, but living an hour or more away from a population center, or even just a community hospital, puts you in a certain category of risk. If anything, the more rural the location of response, the greater the need for a higher level of EMS provider.

Let me propose this scenario: An on-duty police officer that is certified as an EMT arrives on the scene of a medical emergency. In his patrol car he has an AED, a face mask for ventilations, and a small kit with some bandages. A BLS ambulance staffed with two certified EMTs arrives at the same time. The patient has a very low blood pressure. It is because of an SVT. No one knows this because no one there has a cardiac monitor. Even if there was a monitor there, none of the three is capable of interpreting ECGs. In this scenario, we have three individuals certified to respond to medical emergencies and none of them can adequately treat the current problem. If this had been a life-threatening event, such as cardiac arrest, choking, or major bleeding, then the police officer could have provided an equal level of care to that of the ambulance crew.

To my knowledge there is no other licensed healthcare provider (in the US) with less education or training than in EMS (in the US). How can we hope for anything more when we expect so little of ourselves?

I don't think hurt feelings are too big of an issue:) regarding other licensed healthcare provider (in the US) with less education or training than in EMS (in the US) our local CNA classes are 75 hours in length as opposed to the 182 of the emt class. Not that I'm excusing the lack of scope of our Basic classes, simply wanted to clarify. This is a fascinating debate. In an ideal world I suppose every rig would be crewed by 2 people of at least paramedic level of training and education. My assumption is that most basics would prefer to be medics. The 2 major problems involved in upgrading ones education, at least from my perspective, are cost and time. Medic school costs more than half of my yearly take home pay. The time factor occurs because I need to work at minimum 55 hours a week to meet my living expenses. When I start medic school that's no longer going to be an option. I'll probably need to take out a loan for tuition and cut it back to ramen noodles twice a day again. It's worth it to me because I picked this field and I'm damn well gonna stick with it but I'm not sure how many current basics will be willing to live like a monk for the better part of 2 years in order to provide better patient care. In a perfect world the answer would be "every last one of us" but I'm a little too old to believe in perfection.

The current emt education system is sadly lacking, no one can deny that. Any fresh emt can figure that out shortly after he or she starts working. I attend every class that's offered by our medical director's hospital (because they're free for me) and several of them, in my opinion, would be fairly easy to fold into the current emt-b curriculum if they took the class from 5 months to 8 or 9. Hell, make it a year. and 2 years for medics. But companies will need to adjust to the new educational requirements as well. I.E. -pay more than McDonalds.

@Kiwi: Kiwi, what do your first responders do? Work concerts/festivals and things like that, or is it more of a volunteer cert held by people with other jobs (teachers, sanitation, movie theater workers etc)? If it's a 16 hour training session then there's really no reason not to teach it to everyone who interacts with the public. That might be a helpful and fairly simple idea to implement over here. Does the class include AED/cpr too?

[BAYAMedic]

im not arguing the point that it hurts or helps but who will pay for it when training budgets are already stretched to the breaking point. Its fine and dandy for us who are already medics to say move on or get out of the way but what if the current medic was now obsolete and all the medics were told to either get the new cert or get out of the way. I would bet that you would be singing a different toon.

Could your agency afford to educate or send all your medics to the next level or can your agency afford to send all of your emts to the medic level based on the mandate proposed by the OP? Ill bet that most agencies cannot afford to send their people to enough ceus to keep their licences current let alone put them back through school to get to the medic level.

I spent 20k US to get my Paramedic. Out of my pocket. Out of my class of 24 students only 3 were sponsored by agencies. Very similar ratios exist in the 3 other programs I am familiar with. It doesn't come down to the training budgets, It comes down to people driven to the industry. Does every hospital babysit their nurses and make sure they attend all required CME's and bolt on certs and give them time off to ensure they do them? Or do they expect them to be adults and maintain their licensure?

Its been said before and I will say it again. Every county/city has a garbage man and every hospital has an RN, both of which get paid better than the average street medic. I feel like we need to be doing more public education of what we do before it comes to levy year for EMS. then they know what that % of assessed values goes to rather then another tax added.

FIreman1037

[Kiwiology]

The First Responder class is for volunteers community response groups who operate in rural and remote areas to provide immediate care prior to the arrival of the ambulance. The people who work at events are also taught this class.

It covers first aid, AED, basic oxygen administration and how to give oral glucose and provide aspirin for self administration in the event of suspected myocardiacal ischaemia. Note "self administration" i.e. they must give the patient aspirin for themselves to take on their own volition, a First Responder is not legally allowed to determine that administration of medication is required but they can supply it for the patient to take, the difference is subtle but important. A First Responder is not authorised to use any clinical equipment e.g. SPO2, ECG, BP nor to transport a patient or crew an ambulance.

Edited June 20, 2012 by Kiwiology