Paramedics Providing Care?

[ohiovolffemtp]

Most of the arguments about expanding the scope of care provided by paramedics seem to be falling into two categories:

1. I had this bad experience where a paramedic mis-handled a situation and this bad thing happened.

2. Paramedic training is just "trade-school" classes and not true medical education.

 

Neither provide the validity needed to preclude paramedics doing more than 911 type emergent responses or interfacility transports.

 

Each of us can cite many examples of excellent care provided by physicians, mid-levels, nurses, paramedics, and other providers. Each of us can also cite many examples of poor care provided by the same list of providers, and supplement it with how other providers, whether at higher or lower levels of training, caught those mistakes. None of this makes it possible to generalize from these specific cases to all providers of that level.

 

I've taught at both a university based paramedic program and an in-house paramedic program run by a large career fire department. Neither was "trade-school" education. We covered anatomy & physiology, pathophysiology, pharmacology, etc. This was the underlayment to the patient assessment and treatment education. It must have worked. Pass rates on the National Registry exam - the national exam most states use for paramedic certification - for both programs was above 95%. The paramedics must have learned well - they perform well in the field and continue to learn. Their knowledge must be pretty solid within their areas of expertise - the local university hospital uses them to train their nurses, residents, and staff physicians in ACLS, airway management, etc.

 

Expanding the scope of paramedics to do routine screenings, wound management, etc can work. You have to choose the proper persons and give them the right training. Just as not all RN's have what it takes to be good NP's, not all medics will have what it takes to do well in the expanded roles. Whether it's attractive for an area to do this will depend on local circumstances. An urban area with a stressed 911 system and plenty of hospitals might not get much value from it. A rural area with very limited hospital availability and long travel times might benefit from it greatly.

[ventana]

Apples and oranges...

 

1.) New Grad PA-Cs... generally are NOT allowed to roam the country-side seeing patients independently. For the most part, many/most/all(?) states require close supervision of new grads by doing things like requiring chart review AND cosignature and restricting the use of new grads at "remote-sites."

 

not sure this is correct - the AAPA stance on supervision is to be defined by the PA/Doc team with out any 'legal requirement'. States all have different rules but I know Mass and NY it is pretty much a blank slate (and a new grad could be no where near SP and no real supervision)- AK does have some restrictions on in attendance supervision for new grads but unsure of the other 47 states

[ventana]

Apples and oranges...

 

1.) New Grad PA-Cs... generally are NOT allowed to roam the country-side seeing patients independently. For the most part, many/most/all(?) states require close supervision of new grads by doing things like requiring chart review AND cosignature and restricting the use of new grads at "remote-sites."

 

not sure this is correct - the AAPA stance on supervision is to be defined by the PA/Doc team with out any 'legal requirement'. States all have different rules but I know Mass and NY it is pretty much a blank slate (and a new grad could be no where near SP and no real supervision)- AK does have some restrictions on in attendance supervision for new grads but unsure of the other 47 states

[Contrarian]

Again... for those that missed it the first time.

 

It has already been determined that the minimum level of training required to make these "treat-transport-street" triage decisions in the civilian population, WITH close physician supervision is the PA/NP level of training.

 

So... training medics to the knowledge level they would require to make 'safe-sound,' conservative, but thorough triage decisions is the key here. The issue seems to be that the MINIMUM level/amount of training needed to get them safely/competently prepared to do this will essentially make them PAs.

 

Sooo.. why not just send them to PA school or simply hire PAs... ????????????

 

It occurs to me that what's being suggested may not only lead to "regulars"... "frequent flyers" and the unsavory recieving biased, substandard and maybe dissmissive, cursory care... but may also lead to PAs being locked out of EM in 20yrs... because the prefered and cheaper provider in that area of medicine will be this hybrid EMT-P with additional sub-PA level training and less tuition debt.

 

Think about it...

Once they are allowed to make these decisions in the back of the bus, out on the street... what would be the justification/rational for not allowing them to do the same in all EDs...??? Why wouldn't all EDs station a few of these at the entrances, in the lobbies/waiting rooms, since they have the skill, knowledge to appropriately triage folks...???

 

Cooool... 20 yrs from now PAs will not only be in heavy competition with Dr. NPs for Jobs, but will now have to compete with Super EMT-Ps... true "ParaGods"... as well for emergency medicine positions...

 

Yeah... sounds like a GREAT idea for PA-Cs to get behind and support...:heheh:

[Contrarian]

Again... for those that missed it the first time.

 

It has already been determined that the minimum level of training required to make these "treat-transport-street" triage decisions in the civilian population, WITH close physician supervision is the PA/NP level of training.

 

So... training medics to the knowledge level they would require to make 'safe-sound,' conservative, but thorough triage decisions is the key here. The issue seems to be that the MINIMUM level/amount of training needed to get them safely/competently prepared to do this will essentially make them PAs.

 

Sooo.. why not just send them to PA school or simply hire PAs... ????????????

 

It occurs to me that what's being suggested may not only lead to "regulars"... "frequent flyers" and the unsavory recieving biased, substandard and maybe dissmissive, cursory care... but may also lead to PAs being locked out of EM in 20yrs... because the prefered and cheaper provider in that area of medicine will be this hybrid EMT-P with additional sub-PA level training and less tuition debt.

 

Think about it...

Once they are allowed to make these decisions in the back of the bus, out on the street... what would be the justification/rational for not allowing them to do the same in all EDs...??? Why wouldn't all EDs station a few of these at the entrances, in the lobbies/waiting rooms, since they have the skill, knowledge to appropriately triage folks...???

 

Cooool... 20 yrs from now PAs will not only be in heavy competition with Dr. NPs for Jobs, but will now have to compete with Super EMT-Ps... true "ParaGods"... as well for emergency medicine positions...

 

Yeah... sounds like a GREAT idea for PA-Cs to get behind and support...:heheh:

[Just Steve]

 

Just a short vid clip of what is a very typical situation in large cities everywhere. The solutions that are on the table to ease the crush of medical need in this country are not currently effective. With now over 140 PA programs in the nation, we may dig our way out some year, but with the explosion of people entering their later years (baby boomers) coupled with the steady climb of obesity and related diseases, I am not convinced medical providers will ever catch up with medical need.

 

PA program was born from thinking outside a box. I happen to find it a most outstanding plan. But I really don't think it is the only viable plan. Brainstorming often fills the table with somewhat outlandish ideas but more often than not, it produces viable options. Advanced paramedics can be one of those viable options in my opinion. The military does it/has done it for decades. Young, non college educated "technicians" make decisions to treat on the spot or evac every day without the direct supervision of a PA/NP/MD. It isn't always perfect but neither is 12-24 hour wait times in ERs

[Just Steve]

 

Just a short vid clip of what is a very typical situation in large cities everywhere. The solutions that are on the table to ease the crush of medical need in this country are not currently effective. With now over 140 PA programs in the nation, we may dig our way out some year, but with the explosion of people entering their later years (baby boomers) coupled with the steady climb of obesity and related diseases, I am not convinced medical providers will ever catch up with medical need.

 

PA program was born from thinking outside a box. I happen to find it a most outstanding plan. But I really don't think it is the only viable plan. Brainstorming often fills the table with somewhat outlandish ideas but more often than not, it produces viable options. Advanced paramedics can be one of those viable options in my opinion. The military does it/has done it for decades. Young, non college educated "technicians" make decisions to treat on the spot or evac every day without the direct supervision of a PA/NP/MD. It isn't always perfect but neither is 12-24 hour wait times in ERs

[EMEDPA]

 

Why wouldn't all EDs station a few of these at the entrances, in the lobbies/waiting rooms, since they have the skill, knowledge to appropriately triage folks...???

 

:

 

it's called the nursing lobby. they would never allow it. organized nursing consistently fights against medics having any role in emergency depts and hospitals, even as techs. they argue that a cna is better prepared in 80 hrs to work as an er tech than a medic with well over 1000 hrs of training.

for most medics nurses(at least nursing admin/lobby) are the enemy, plain and simple.

some depts have the right idea and allow emt-p basically the same latitude as an er nurse with few exceptions outside their scope of practice(hanging blood for example). at one facility near me if an er doc is not immediately available they call a dept medic to the room for codes, not a nurse.

[EMEDPA]

 

Why wouldn't all EDs station a few of these at the entrances, in the lobbies/waiting rooms, since they have the skill, knowledge to appropriately triage folks...???

 

:

 

it's called the nursing lobby. they would never allow it. organized nursing consistently fights against medics having any role in emergency depts and hospitals, even as techs. they argue that a cna is better prepared in 80 hrs to work as an er tech than a medic with well over 1000 hrs of training.

for most medics nurses(at least nursing admin/lobby) are the enemy, plain and simple.

some depts have the right idea and allow emt-p basically the same latitude as an er nurse with few exceptions outside their scope of practice(hanging blood for example). at one facility near me if an er doc is not immediately available they call a dept medic to the room for codes, not a nurse.

[ohiovolffemtp]

In SW Ohio, ER's do use medics to triage.

 

Also, in SW Ohio, as in many other areas of the country, paramedics do have the authority to treat and release in a few circumstances. The major situation is hypoglycemia. If the patient returns to normal alertness with D50, they are instructed to eat - most paramedics wait and watch this happening - and then are permitted to refuse transport. Other scenarios that I have been a part of include cleaning and dressing minor wounds, suctioning trachs, and repairing problems with home O2 devices. Paramedics are also permitted to make decisions on whether full cervical spine immobilization is needed or not, whether transport is to be done emergent or not, or whether the paramedic needs to accompany the patient to the hospital vs. being transported by EMT-Basics. During the H1N1 scare, paramedics were given the authority to discourage transport of patients that met certain criteria.

 

The proper question is not a debate about the "minimum level" of credential needed to make a transport/no-transport decision. Rather, it is about what circumstances can be delegated to an appropriately trained paramedic. Medical oversight should be a part of this process - just like it is for all healthcare providers.

[ohiovolffemtp]

In SW Ohio, ER's do use medics to triage.

 

Also, in SW Ohio, as in many other areas of the country, paramedics do have the authority to treat and release in a few circumstances. The major situation is hypoglycemia. If the patient returns to normal alertness with D50, they are instructed to eat - most paramedics wait and watch this happening - and then are permitted to refuse transport. Other scenarios that I have been a part of include cleaning and dressing minor wounds, suctioning trachs, and repairing problems with home O2 devices. Paramedics are also permitted to make decisions on whether full cervical spine immobilization is needed or not, whether transport is to be done emergent or not, or whether the paramedic needs to accompany the patient to the hospital vs. being transported by EMT-Basics. During the H1N1 scare, paramedics were given the authority to discourage transport of patients that met certain criteria.

 

The proper question is not a debate about the "minimum level" of credential needed to make a transport/no-transport decision. Rather, it is about what circumstances can be delegated to an appropriately trained paramedic. Medical oversight should be a part of this process - just like it is for all healthcare providers.

[brookspa]

no one has mentioned the very limited availability of Paramedics when things begin to happen . I remember 30 calls in a 24 hr shift...two full dual tanks of fuel in a shift, the lack of any back up with 3 calls holding hoping a first responder could hold it together till we could get there...the logistics just SUCK. And contrarian is right again...this is just a power play. Paramedics are regional, local and at best state. NO national leadership, organization ect...their pay is lousy in most places and those who are motivated DO go to PA or NP school. I have had fellow medics go to med school(at least 3 i remember)..

Sounds silly on the face and worse on the road. I was a EMT-P for 9 years urban and rural. just my .02. Bad idea.

[brookspa]

no one has mentioned the very limited availability of Paramedics when things begin to happen . I remember 30 calls in a 24 hr shift...two full dual tanks of fuel in a shift, the lack of any back up with 3 calls holding hoping a first responder could hold it together till we could get there...the logistics just SUCK. And contrarian is right again...this is just a power play. Paramedics are regional, local and at best state. NO national leadership, organization ect...their pay is lousy in most places and those who are motivated DO go to PA or NP school. I have had fellow medics go to med school(at least 3 i remember)..

Sounds silly on the face and worse on the road. I was a EMT-P for 9 years urban and rural. just my .02. Bad idea.

[Just Steve]

no one has mentioned the very limited availability of Paramedics when things begin to happen . I remember 30 calls in a 24 hr shift...two full dual tanks of fuel in a shift, the lack of any back up with 3 calls holding hoping a first responder could hold it together till we could get there...the logistics just SUCK. And contrarian is right again...this is just a power play. Paramedics are regional, local and at best state. NO national leadership, organization ect...their pay is lousy in most places and those who are motivated DO go to PA or NP school. I have had fellow medics go to med school(at least 3 i remember)..

Sounds silly on the face and worse on the road. I was a EMT-P for 9 years urban and rural. just my .02. Bad idea.

 

I am willing to bet that for every heinous shift where you got your backside handed to you, you can name at least an equal number of days where you sat around and watched the paint dry. Paramedic scope is limited by what their medical director decides to allow them to do. For any change to happen it would have to be a top down approach...hence my doubts that the status quo will ever change....but something has got to give.

[Just Steve]

no one has mentioned the very limited availability of Paramedics when things begin to happen . I remember 30 calls in a 24 hr shift...two full dual tanks of fuel in a shift, the lack of any back up with 3 calls holding hoping a first responder could hold it together till we could get there...the logistics just SUCK. And contrarian is right again...this is just a power play. Paramedics are regional, local and at best state. NO national leadership, organization ect...their pay is lousy in most places and those who are motivated DO go to PA or NP school. I have had fellow medics go to med school(at least 3 i remember)..

Sounds silly on the face and worse on the road. I was a EMT-P for 9 years urban and rural. just my .02. Bad idea.

 

I am willing to bet that for every heinous shift where you got your backside handed to you, you can name at least an equal number of days where you sat around and watched the paint dry. Paramedic scope is limited by what their medical director decides to allow them to do. For any change to happen it would have to be a top down approach...hence my doubts that the status quo will ever change....but something has got to give.

[Just Steve]

removed by choice

[Just Steve]

removed by choice

[Davo]

A great idea, IMO. In various forms, its been around for a bit.

[Davo]

A great idea, IMO. In various forms, its been around for a bit.

[Jambi]

http://www.jems.com/article/news/wisconsin-pilot-program-uses-paramedics

 

BARABOO - A new pilot program in Baraboo will examine whether paramedics trained specifically to perform in-home health care can lower the number of people coming into the emergency room and also reduce re-admissions to the hospital.

 

The five-year pilot study involves the Baraboo District Ambulance Service, St. Clare Hospital and the University of Wisconsin School of Medicine and Public Health and other partners in Sauk County to create a community paramedics program.

 

Dr. Marv Birnbaum, emeritus professor of medicine and physiology at UW-Madison, said grant and foundation funds already are being sought for the program. He said the program could cost about $1.3 million, which will go to pay instructors and the paramedics while they're in school training for six months. He said funds also will be put aside to study and evaluate the program.

 

"Eventually, this program will become self-supporting," he said. "We are really looking to get this started."

 

Sandy Anderson, president of St. Clare Hospital, said the pilot program is aimed at people not sick enough to go to a nursing home or have home health care.

 

Baraboo District Ambulance Service Chief Dana Sechler said the program is designed to fill in the gaps sometimes associated with follow-up care.

 

"We are simply adding another member to the team to help when a person comes home from the hospital to make sure the person is doing all the right things to get healthy," Sechler said.

 

Birnbaum said after paramedics are trained on primary health care such as in-home evaluations and assessments of people with asthma or pulmonary disease, they can then operate on referrals from the patient's primary physician or practitioner to check on the patient.

 

Birnbaum said the aim of the community paramedic program is to improve the health of the patient who comes home from the hospital, and to keep them from going back to emergency rooms that are sometimes already overloaded with patients.

 

Baraboo District Ambulance Service Capt. Lori Spencer said currently the safety net for most people is their local hospital's emergency room.

 

Sechler said once a patient is discharged from the hospital and gets a referral from a doctor, the community paramedics will make contact with that patient within 24 hours.

 

Medicare payments for unplanned readmissions in 2004 totaled $17.4 billion, according to a study completed by the The New England Journal of Medicine. The same study concluded that one in five Medicare patients who were discharged from a hospital between 2003 and 2004 were rehospitalized within 30 days; and one and three patients were back in the hospital within 90 days.

 

"This program can help mitigate those numbers, save money and keep people healthy," Spencer said.

[jesscbv]

The issue seems to be that the MINIMUM level/amount of training needed to get them safely/competently prepared to do this will essentially make them PAs.

 

 

This is what I'm most concerned about: if Medics are given a broader scope of practice, will patients be getting the best care? Patient safety is #1. Yes, we want to make health care more efficient and more accessible, but not at the expense of patient safety. Probably, based on the kind of HCE that schools seem to value, having the experience of being a Medic would prepare you wonderfully for PA school.

[Contrarian]

Right...

 

So after adding this 6mo course, they now have the knowledge and skills to do what Licensed and Certified PA-Cs already do (decide who needs to be seen by a PA/physician, who doesn't need a CT/MRI/C-Xray/BLE Ultrasound, who needs to take more/less insulin, who needs supplemental O2 and at what lpm, etc.)..???

 

Hell... it takes a history and exam from a fully trained physician or PA BEFORE this highly trained provider can safely, actually decide if a patient needs further lab testing or imaging... but this 6month course is gonna adequately prepare a medic to make these decisions...??

 

What's the point in Paramedics actually attending PA school if all it takes is a 6month in house course to essentially do what PA's do....???

 

Do they call a PA/Physician if not sure...??? If so... then shouldn't "Med-Control" have sent a PA/Physician to begin with instead of further delaying care...???

 

So adding this 6mo course to a EMT-P (Paramedic) makes them what...??? Sort of PAs... PAs... "PA-Bypasses"... What...???

 

Again... just don't see the utility in this except to increase the liability of a few departments and medical directors... since if these folks are gonna, sort of, kinda act/practice like PAs then why not simply hire the real deal (a few experienced EM PAs)... or just PA-Cs and send them to a 6mo EMT-P course since there are plenty of those courses around or a few new grads who were former medics.

 

But hey... smarter people that me have apparently figured this out so more power to them...

Gonna be interesting to see what EMPA utilization is gonna be like in WI in a few yrs.

 

My $0.02...

 

YMMV

 

Contrarian

[EMEDPA]

my quick read of this is that they are not training medics as pa's but as lpn's doing home health nursing. not a big leap as the medic scope is already larger than that of an lpn who in many situations is NOW doing these evals and making decisions about the pts treatment and need for further eval.

in california they used to give lpn certs to any medic who asked for them by reciprocity without any additional testing so to me it looks like a home health medic is actually overtrained for the work they will be doing.

I'm not a fan of medics doing extended scope pa skills like suturing that they would not practice often enough to be competent but it doesn't sound like that is part of this. maybe I don't know enough about this particular program but I don't think this represents a threat to pa's but to visiting nurses.

[kargiver]

I don't see the point of this... first, EMS systems are generally overtaxed, particularly in the environments where I suspect they want to target. Taking an ALS rig out of service for an extended period to do a lac repair strips necessary services elsewhere. Second, who is going to write the RXs for theses various conditions? Can you imagine being able to call a medic to your house for a RX refill of their vicodin (IT WILL HAPPEN NO DOUBT)... Finally, how will reimbursement work? There is nothing set up for this so this has "Money loser" written all over it. We can't afford it.

 

The conceirge approach to medicine has to stop (unless you can actually afford it out of your OWN pocket, not the governments pocket). This is a luxury that cannot be afforded and will lead to more abuse in the system. If folks really think this is a reasonable approach put PAs or Acute care NPs in the field to do this work (so they can actually bill for it). I would like to see how an ambulance service bills for a lac repair under medicare that isn't done by an LIP or Doc and not get charged with fraud...

 

Having done both EMS as a medic and working as an EM PA, the education models are apples and oranges. Six months isn't enough to "fill in the gaps." It'll just lead to sh*tty medicine.

 

G

[jannypan]

I do believe there is a niche for it out there. You just have to find the right medics to do it. It's a mind set as much as it is a skill set.