For American EMS - A different question...

[vs-eh?]

I see posts all the time for people trying to justify either for or against for EMT-XYZ should or should not be doing X procedure. Why educational requirements should be this or shouldn't. Why should I have to do this or that...

Why!?

From what I have seen, people here do not generally dispute Ontario's educational requirements. Nor do they dispute the fact that generally (especially on a BLS level) they are light years ahead of current American standards. It should be noted though...I am speaking for Ontario only, not Canada as a whole. There are differences in education at all paramedic levels across the country, as well as differences in scopes of practice. Some could be seen as better, some worse. This should not be seen as representative of the entire country, just as a California or New York State perspective should be seen as what it is for the entire country. However, generally speaking, Canadian EMS education exceeds that of our American neighbours.

I don't think this is ever disputed...

I will again offer an outline of both PCP and ACP education and reference a single program for a general comparison. I will then give the general scope of practice and pharmacological intervention. Then pose a question...

*Note* I will leave out Critical Care Paramedics (CCP). They are a "rare" paramedic and generally do not function in "normal" EMS in Ontario. By normal I mean 911 land, what the average person would see as what ambulance is. They do exceed ACP scope and education substantially though in Ontario.

PCP (Primary Care Paramedic) http://postsecondary.humber.ca/07651.htm

- 2 year college diploma

- Approx. 800-1000 hours of didactic, ~ 100 hours of clinical, and 350-500 hours of ambulance precepting. Typical hour totals range from 1200-1600

Scope of Practice

- BLS airway interventions with rare services using alternate airways (i.e. CT and LMA)

- SEAD, 3/12 lead monitoring (though generally not formally allowed to interpret, although it generally wouldn't matter). Not all services have 12 leads.

- Minority of services allow PCP IV starts, some only with ACP partners.

- Basically the general scope of what is considered BLS by most standards

Drugs and standing orders (all drug admin is done at the paramedics discretion and nothing needs to be "called in")

- NTG spray (for ischemic CP or CHF)

- Epi 1:1000 (for anaphylaxis, asthma, or croup)

- Glucagon (diabetic problem)

- ASA (ischemic CP)

- Salbutamol (SOB)

I think some services may carry glucose tabs or something. Some services allow PCP's to administer D50W, but again very rare (by rare I mean like a handful).

Generally speaking the above 5 drugs are the PCP drug list.

ACP (Advanced Care Paramedic) http://www.conestogac.on.ca/jsp/cecatf/health/acp.jsp

- Approx. 1 year post-diploma

- 300-400 hours didactic, 160-240 clinical, and 480-720 precepting. About 1000-1400 hours...

- Obviously they are banking on a solid didactic foundation

Scope of Practice

- intubation (including lighted stylet in some rare services), rare services have alternate airways, surgical airways (needle/surgical cric), chest needles, ETCO2 (some waveform, some not)

- pacing, cardioversion, manual defib, 3/12 lead interp.

- IV/IO (ped)

Drugs (Can be used for all applicable drugs indications - i.e. amio is used not only in an arrest but also for stable VT or some afibs, etc...)

*Note* ACP's on land basically NEVER hanging any infussing medications (other than dopamine).

- Adenosine

- Amiodarone

- ASA

- Atropine

- D50W

- Diazepam

- Diphenhydrinate (rare in services)

- Dopamine

- Epi - 1:1000, 1:10,000

- Fentanyl (this is basically an either/or situation now; either fent or morphine)

- Furosemide (not under standing order here and very very rarely used)

- Glucagon

- Lidocaine

- Midazolam (including use for PAI with an analgesic)

- Morphine (see Fentanyl)

- Naloxone

- NTG

- Salbutamol

- Sobium Bicarb

- Xylometazoline (for nasal tubes)

Given the above outline for those that were not aware, my questions...

Why do you think Ontario paramedics have a generally equivalent or lower scope of practice/drug availability compared to American EMT-B's and EMT-P's? I am using my impression based on what is said on these boards. Grain of salt perhaps, but still...

Do you consider Ontario paramedics (especially PCP's) overeducated for what they can generally do?

Would you come to Ontario and (assuming you could) enter into EMS education with it's current standards and corresponding scopes? Would you still do it even though following 2 years of PCP education, the job outlook was poor? By poor let's call it a < 20% chance of getting a job as a paramedic.

This is mainly because I see a lot of people who seem like they should be entitled or seen their education as justification for doing certain things. This is all under the guise of "for the patient" of course. This hopefully will give some a bit of a perspective...

[AZCEP]

Speaking for NW Arizona only, it looks like the PCP is well above the standard EMT-B, and the ACP isn't quite to the Paramedic.

Central lines, medication infusions to include Dopamine, Lidocaine, Magnesium, and Epi PRN, surgical airways are the norm. There are a few medication differences besides the infusions, but few of the differences are used with any regularity.

National sScope of Practice aside, very few providers are educated to the level of being able to use all of the suggestions that are in a program. Most will be taught to the level that local protocol allows, no more. Consider also, local medical direction has more influence on what providers can and can't do than state, or national standards do.

Good topic though.

[vs-eh?]

Speaking for NW Arizona only, it looks like the PCP is well above the standard EMT-B, and the ACP isn't quite to the Paramedic.

Central lines, medication infusions to include Dopamine, Lidocaine, Magnesium, and Epi PRN, surgical airways are the norm. There are a few medication differences besides the infusions, but few of the differences are used with any regularity.

National sScope of Practice aside, very few providers are educated to the level of being able to use all of the suggestions that are in a program. Most will be taught to the level that local protocol allows, no more. Consider also, local medical direction has more influence on what providers can and can't do than state, or national standards do.

Good topic though.

You would probably concede though, given that I have not shown a detailed brakedown of the PCP and ACP education, that your comparison to NW Arizona is strictly seen from a procedural point of view. I am assuming this.

I think a lot of people simply look at it this superficially. They see a collection of procedures, and in turn infer that "standards" are not being met in comparison.

I think a lot of people on this forum see EMS level as simply a set of procedures, a "what can I do", and that seems to define them. If an EMT-B sees/or thinks that they should/can do an IV, that "sets them apart", makes them "more educated". Or if an EMT-P administers Lopressor that they have "an edge", perhaps in a greater educational scheme.

This is flawed thinking. It is also ironic considering the vast majority of calls require only BLS. I sure most would agree that an educated BLS paramedic with a limited scope is far better FOR THE PATIENT, than an under-educated BLS paramedic with a greater scope.

Hmmmm?

I would wager that NO PCP will be able to use every piece of education or procedure that they were educated or instructed on. I was shown the how's and why's of cardioversion and pacing, EKG interp, pretty in depth pharm, started 50+ IV's in clinical, etc...etc...Could I physically/practically USE those as a PCP where I worked? No...No PCP can...Sure as HELL helped when working with ACP's or doing MY OWN assessment though. Sure helps when I updated a ACP crew that the patient was in a 3rd degree block with a good report, knowledge of pharm, etc.. prior to their arrival and they had a mental picture already of what to do. THAT HELPS! It helps that paramedics with more advanced scopes can rely on those that may not currently have them, but who KNOW them.

Thinking and knowing > doing.

PS - ACP's can do EJ's generally. Not a central line but you know...

[BushyFromOz]

There a good opportunity to learn more about North Americac EMS in theis thread, i hope those replying can keep it civil

[AZCEP]

Absolutely correct. I am judging based on the procedural content. The descriptions you give for the program length is along the same lines. PCP well beyond, ACP not quite the minimum.

With the program content differences better delineated, it might be possible to view things differently. Also consider the number of clock hours of "empty" content in most programs. 1500 total hours with 700 clinical, and roughly 120-200 dedicated to review prior to the final examination.

[akroeze]

Absolutely correct. I am judging based on the procedural content. The descriptions you give for the program length is along the same lines. PCP well beyond, ACP not quite the minimum.

With the program content differences better delineated, it might be possible to view things differently. Also consider the number of clock hours of "empty" content in most programs. 1500 total hours with 700 clinical, and roughly 120-200 dedicated to review prior to the final examination.

Just wondering, are you taking into account that you must be a PCP before ACP? Combined the hours would look like this:

1100-1400 didactic

260-340 clinical

830-1220 precepting

Which is:

2190-2960 total

(54.75-74 40hr work weeks, personally it means more when I look at it that way)

Just wondering how these combined totals compare to some EMT-P programs?

[AZCEP]

Even with the combined totals, there is not a direct correlation between them.

BLS:

110 classroom hours

24 clinical/vehicular

Paramedic:

500-600 classroom

500-700 clinical/vehicular

So from off the street to paramedic graduate with no field experience in between:

Roughly 1350 hours total

Most will take the BLS course, then work for a period of time before deciding to go further but this isn't a requirement of all programs.

[vs-eh?]

Most will take the BLS course, then work for a period of time before deciding to go further but this isn't a requirement of all programs.

http://www.conestogac.on.ca/jsp/cecatf/health/acp.jsp

2500 hours or more work experience as a PrimaryCare Paramedic

Which equals 18 months or so minimum as a PCP in a service prior to applying.

This is pretty much a standard (minimum).

[ERDoc]

Out of curiosity, what kind of central lines are being put in by field providers? Where I'm from the most invasive line is an EJ and this does not constitute a central line.

[akroeze]

So basically an ACP has roughly double the time put into their education that an EMT-P does and they have slightly less "skills"?

vs:

Some colleges do take admissions with little to no PCP experience (Algonquin for one).

I'm thinking of applying to it for this coming session, although admittedly by then I'll probably have 1500-2000 hours under my belt.