EMS Educational Standards

[Fire-ALS]

. In-house A&P is hit or miss, and will never cover what a college level one does.

My in-house A&P covered more than my college level general A&P did with the exception of bones. The only thing we didn't have was the lab.(truthfully I learned very little clinically significant information in my lab, although it was cool to feel a lung) But my medic instructor is an A&P instructor at the school and this may be the exception to the rule.

A&P doesn't teach you capnography/capnometry

misunderstood your statement linking the two.

I'm all about advancing Fire/EMS, especially at the ALS level but I don't think a degree requirements are the way to go. Accreditation to ensure the quality of education being provided is. A paramedic can only be as good as the information taught.

Instead requiring a degree, have prerequisites of: EMT-B, General A&P, Adv A&P and microbiology before being to apply for paramedic. Even pharmacology if you want.

[edpmedic]

My in-house A&P covered more than my college level general A&P did with the exception of bones. The only thing we didn't have was the lab.(truthfully I learned very little clinically significant information in my lab, although it was cool to feel a lung) But my medic instructor is an A&P instructor at the school and this may be the exception to the rule.



misunderstood your statement linking the two.

I'm all about advancing Fire/EMS, especially at the ALS level but I don't think a degree requirements are the way to go. Accreditation to ensure the quality of education being provided is. A paramedic can only be as good as the information taught.

Instead requiring a degree, have prerequisites of: EMT-B, General A&P, Adv A&P and microbiology before being to apply for paramedic. Even pharmacology if you want.

The first problem is, we bill for txp, rather than skill hours. It's mileage plus the category ot txp, such as BLS, ALS1, ALS2, etc. In nursing, for example, there is a certain dollar amount attatched to equipment, and a certain amount of time attatched to the procedure. Those are called skill hours. Paramedics would have to be recognized nationally as "licensed providers." New revenue streams for the FD and also in non fire EMS will become available. BCBS and Medicare are already trying to further curb insurance reimburstments:

http://www.boston.com/lifestyle/heal...h_care_reform/

"Community Outreach" paramedics (or whatever you want to call them), that perform a function similar to visiting nurses, starting with targeted chronic 911 callers, will help to lower call volume, which also lowers unnecessary, expensive transports. How much did your insurance premium jump last year? Paramedics in other countries, who typically hols four year parameedic degrees, can treat and release, and also refer to the proper definitive care destination by alternative methods of txp if necessary. We already run 911 EMS at a financial loss. As the polulation grows, we're just going to put more medic units on the street, and also more engines since 70% or so of their call volume is ALS first response. EMS in the U.S. is just a catch-all for anything and everything medical. It can be more than that, as is evidenced elsewhere. Not transporting everyone to the hospital saves a lot of money in billing for the healthcare system in general.

As far as protocols, anyone trained to do an assessment and psychomotor skills can do our job. Some systems do this now with the EMT-E (or A), where they can give some of the most important drugs, transmit an ECG, and just carry out whatever the OLMC doc says to do. Educated providers can instead use clinical guidelines and treat according to their scope of practice and clinical judgmant. You need a degree for this.

EMS isn't only 911 ambulance txp. You have IFT, CCT, medics working in the ED and sometimes the ICU, etc. Do a four year degree, and you can specialize, just like nurses. Years one and two, gen ed. Year three, the paramedic curriculum for the puropses of NREMT testing. Year four, a specialty. This can be CCT and flight, an Emergency Care Paramedic who works in the ED, Critical Care for the ICU (not CCEMT-P), or Community Health, who can work in a doctor's office, do treat and release in the field, etc. You build these bridges, and higher salaries through negotiation will come.

[edpmedic]

If a patient needs to be taught how to manage their disease, then that education should be provided by their PCP or clinic, NOT by EMS during a 911 response. Just like you can't teach a paramedic the "background" knowledge of most diseases in order to make the type of independent treatment decisions you are advocating for in less than an hour, you won't be able to teach somebody to manage their disease in the time frame that EMS is typically with a patient (less than an hour). Part of properly managing any medical condition is the inclusion of a physician. That's where education regarding chronic medical conditions should be done.

See above post.

[edpmedic]

Do you also advocate EMS providing on scene psychiatric counseling?

You mean like this?

http://www.co.sanmateo.ca.us/portal/...tcurrchannel=1

[FireMedic049]

See above post.

I think you're blurring the line a bit. A paramedic working in the ER, ICU, doctor office, clinic, etc is not EMS.

While it's certainly possible and maybe even appropriate to provide some of the "community outreach" you describe via the local ambulance service, doing so doesn't make them "Emergency Medical Services" any more than providing wheelchair van services does.

As far as protocols, anyone trained to do an assessment and psychomotor skills can do our job. I think that's an overly simplistic view of the job and doesn't acknowledge that there's a difference between "doing the job" and doing it well.

Educated providers can instead use clinical guidelines and treat according to their scope of practice and clinical judgmant. You need a degree for this. I don't know about where you practice, but I can pretty much already do this now. I can also treat & release patients and refer patients to alternate resources. Sometimes it just needs run past a medical command physician first.

You appear to be advocating for degree paramedic programs in order to create something along the lines of an "expanded practice paramedic" and provide "non-traditional" pre-hospital services. I have no problem with this concept however, I don't see a true need for every paramedic to be trained to this level.

Not every doctor is a cardiologist, oncologist, surgeon, etc. So why does every paramedic need to be trained for an "expanded practice" role?

[FireMedic049]

You mean like this?

http://www.co.sanmateo.ca.us/portal/...tcurrchannel=1

No. I was referring to what appeared to be your belief that EMS (as in 911 system medical response resources) should be teaching patients, who have called 911, how to manage their medical condition rather than them being instructed by those who actually diagnosed them and prescribed medications for it.

Just wondering if you felt that these same medical response resources should pull out their portable couch on a psych call and provide psychiatric counseling on the scene rather than having the patient be treated by their own psychiatrist or other psychiatric professionals?

[edpmedic]

I think you're blurring the line a bit. A paramedic working in the ER, ICU, doctor office, clinic, etc is not EMS.

While it's certainly possible and maybe even appropriate to provide some of the "community outreach" you describe via the local ambulance service, doing so doesn't make them "Emergency Medical Services" any more than providing wheelchair van services does.





You appear to be advocating for degree paramedic programs in order to create something along the lines of an "expanded practice paramedic" and provide "non-traditional" pre-hospital services. I have no problem with this concept however, I don't see a true need for every paramedic to be trained to this level.

Not every doctor is a cardiologist, oncologist, surgeon, etc. So why does every paramedic need to be trained for an "expanded practice" role?

It's not about having every medic educated to be able to fill an expanded practice role. It's about being educated to a certain point as a minimum, and then being able to specialize with some additional education if you choose to do so. That's what nurses do. I'm taken aback by the lack of education that U.S. medics receive, and the lack of standardization in education for the field. Texas has a three month zero to hero program. There are others that run six or nine months. Many of these places are mainly concerned with getting their students to pass the NREMT, nothing more. U.S. medics would not be allowed to be employed as medics in other industrialized nations such as Canada, Australia, Germany, NZ, etc. dur to our lack of education. With a two week in house A&P and a week of pharm, I can't say I blame them. At best, some programs require basic college A&P, usually w/o lab, and pharm. I'd like to see more advanced A&P, like what nurses get, maybe microbiology and O-chem. You're performing invasive procedures and deciding when and where to inject medications into people. Three weeks combined of A&P and pharm is inaqequate. General pharmacology only scratched the surface.

The growing trend in medical insurance reimbursement is to only pay for treatments that are showing a clear benefit to the pt. At some point, we're going to have to justify why a taxi ride to the ED costs $300-500 or more. Maybe 5-10% of our pts are time sensitive, which means that their morbidity/mortality are directly affected by our rapid response and tx. The bulk of this would be the STEMI pt, the CVA pt, the multitrauma pt. Each of these could be handled by an EMT-IV. It's easy to obtain and transmit a 12 as a basic. You're only making money really on respiratory cases, the 2-5% of arrests you may save, and diabetic complications. Maybe another 10-15% need lifting, such as a bed confined elderly pt, or someone with an orthopedic injury. Basics know how to lift people. The rest dont really need "emergency" medical services. In order to keep money in EMS, we're going to need to transfer from mileage based billing to reimbursement by skill hours. No one's going to approve that with EMT-P education being what it is at the present.

The community outreach, working in MD offices, etc. aren't traditional EMS. But the EMT/medic don't only do 911 prehospital txp. The field includes IFT, CCT, flight, and working in the ED. Most EMT-P programs don't prepare the student to function in these environments. A real paramedic should have the education to be able to do CCT, flight, etc. They should be able to do more than just skills in the ED. Nurses don't just work in the ED or on the floor. They specialze in all different types of specialties. Paramedics can do the same. The community outreach services would be one way the FD could see additional revenue from paramedics. I wasn't saying to educate pts while on a call, but rather have a program where the FD sends interested medics around to pt's homes and help them manage their condition, and also to educate as to alternatives to the ED. It's another way for a medic with a broken down body to get off the road, and to get off of shift work if they want. Real treat and release, or to direct txp by alternate means, won't come with our education as it stands currently. Nurses are doing this over the phone in Richmond, triaging pts and informing them of alternatives to EMS response and txp to an ED.

http://icma.org/en/Article/11568/Nur...in_Richmond_VA

Educated paramedics can do the same, whether it's while working at the 911 dispatch center, or on the road. It saves money. The board of supervisors and the bean counters like that.

As far as someone being able to do our job by just learning the skills, I'll reference NYS. Their EMT-CC, which I believe is the equivalent of an EMT-I elsewhere, can do all the skills a paramedic can, but needs to call OLMC for most of their meds and therapies. They're basically just information gatherers for the doctor. That's why anyone trained in a basic assessment and our psychomotor skills can do our job. The difference in education isn't all that great, when compared to what's necessary to practice as a paramedic elsewhere in the world. Some systems even have their paramedics call for everything. I believe L.A. is like that, but I could be wrong. NYC paramedics can't treat two simultaneous conditions at once. If they need to jump protocols, they need to call OLMC, then abandon the first protocol, and then go to the next one. I didn't realize how restricting that was until I left the system. Here, the protocols are more like guidelines. As long as you can justify your action, and are referencing a protocol (or several as the case may be), you're okay. For extraordinary care, you can still call OLMC. It seems to me the NYC REMSCO knows how inadequate our education is, and how the quality of medic can vary greatly from FDNY to the hospitals to the privates, and reflect that in their protocols and SOP's. If paramedics had a better education as a minimum standard, we wouldn't have this problem.

[edpmedic]

No. I was referring to what appeared to be your belief that EMS (as in 911 system medical response resources) should be teaching patients, who have called 911, how to manage their medical condition rather than them being instructed by those who actually diagnosed them and prescribed medications for it.

Just wondering if you felt that these same medical response resources should pull out their portable couch on a psych call and provide psychiatric counseling on the scene rather than having the patient be treated by their own psychiatrist or other psychiatric professionals?

No, but I don't feel that every psych pt needs to go to an ED, where they'll be billed (or the taxpayer will be billed) for an eval by the attending, the psychiatrist possibly, then another bill for BLS txp to a psych facility. That's plenty of waste, and part of the reason why our medical insurance premiums rise so much every year. I don't feel that all psych pts need to go to the ED any more than I feel the majority of our pts need to go to the ED. Getting the pt where they need to go is in their best interests, and indirectly saves us money as well.

[BoxAlarm187]

Real treat and release, or to direct txp by alternate means, won't come with our education as it stands currently. Nurses are doing this over the phone in Richmond, triaging pts and informing them of alternatives to EMS response and txp to an ED.

http://icma.org/en/Article/11568/Nur...in_Richmond_VA

My ex-wife is one of the select RAA triage nurses that does this program...it's quite interesting to see how the EMD integrates with the triage nurse. Ya know what? It's perfectly acceptable to sometimes tell a caller they need to take a $5 bus trip to the ER, not a $500 taxi...uh, ambulance.

Now back to our regularly scheduled discussion...

[DeputyMarshal]

I don't know where you live, but since I was in HS back in the early 90's, and probably before that, you needed at least an RN degree to work as a nurse. Diplomas were no longer sufficient.

I'm in CT. FYI, "RN" isn't a degree. Registered Nurses (RNs) can be either graduates of hospital based nursing programs (diploma nurses) or degree holders from college based nursing programs (degree nurses, usually BSN).

In addition, there's no career advancwment opportunity for anything less than a BSN.

They've been telling nursing students that for 20 years. It still hasn't proven to be the case. There are some (non-patient care) career paths in nursing that require a bachelor's level degree but, in general, direct patient care isn't one of them. Most importantly, a BSN isn't required to be an RN so that pretty well invalidates your argument in faovr of requiring an associates level degree for an EMT-P.

I don't see the quality of medic programs improving on a grand scale.

And you probably won't. Making a degree a requirement just means that you'll see the same mediocre programs cost more and take longer.

with EMS given as a degree, you're assured at least a minimum standard of quality with the program

Sorry, but that's just not a guarantee. If you want higher standards for EMT-Ps, you need to address your EMT-P licensure system.

The instructors would also need to be formally educated to be allowed to teach.

Are you telling me that your insturctors aren't properly trained already? There's your problem.

You lack the inability to understand and implement best practices and evidence based research.

With all due respect, an EMT-P doesn't need that. A mechanic doesn't need to be able to understand thermodynamics or metalurgy to fix an engine; he just needs to know how to use the specific tools in his toolbox. By the same token, an EMT-P doesn't need more than a passing knowledge of pharmacology to administer a small constellation of drugs based on specific protocols.

Most non-college paramedic programs only teach you the bare minimum of A&P and pharm that you need to simply pass the test.

Becasue that's the national baseline of information/skills that an EMT-P is expected to master. If you happen to be in a program that goes further, great! But that's not the standard nor should you expect it to be.

If someone was treating one of your family member...

That's a straw man. I'd want a team of doctors specializing in a variety of disciplines but that's just not realistic.

someone with the educational background to follow the latest studies and research, and be able to apply that to them?

That would be the doctor at the other end of the radio. I don't want somebody with an asssociates degree presuming to be an expert in the "latest studies and research."

I don't plan on moving up the food chain. I like medicine, but I like fire more.

Then it sounds like you've chosen your field. Time to start that degree program in fire science.

[DeputyMarshal]

RNs have rich opportunities.

Yup. And it makes little difference if they're diploma or degree nurses.

[FireMedic049]

It's not about having every medic educated to be able to fill an expanded practice role. It's about being educated to a certain point as a minimum, and then being able to specialize with some additional education if you choose to do so. That's what nurses do.

Ok, now I'm a bit puzzled since Paramedics are already "educated to a certain point as a minimum" and can take on expanded roles with additional education.

I'm taken aback by the lack of education that U.S. medics receive, and the lack of standardization in education for the field. Texas has a three month zero to hero program. There are others that run six or nine months. Many of these places are mainly concerned with getting their students to pass the NREMT, nothing more. U.S. medics would not be allowed to be employed as medics in other industrialized nations such as Canada, Australia, Germany, NZ, etc. dur to our lack of education. With a two week in house A&P and a week of pharm, I can't say I blame them.

Is there a large number of US trained paramedics trying to work in other countries? If not, I don't see this comparison as being all that relevant.

At best, some programs require basic college A&P, usually w/o lab, and pharm. I'd like to see more advanced A&P, like what nurses get, maybe microbiology and O-chem. You're performing invasive procedures and deciding when and where to inject medications into people. Three weeks combined of A&P and pharm is inaqequate. General pharmacology only scratched the surface.

OK, we get that you want a higher standard.

The growing trend in medical insurance reimbursement is to only pay for treatments that are showing a clear benefit to the pt. At some point, we're going to have to justify why a taxi ride to the ED costs $300-500 or more. Maybe 5-10% of our pts are time sensitive, which means that their morbidity/mortality are directly affected by our rapid response and tx.

I whole heartedly agree that we treat and transport far too many patients via ambulance in this country. Moving to degree paramedics is not going to have much of an impact on this problem. The main reason so many people go to the hospital via EMS and some get prophylactic IVs on the way is because of liability concerns.

Our sue happy, coddling society is what is preventing us from telling some people that their "problem" is BS and they need to see their PCP rather than be seen in the ER. Command physicians are worried about the "what if" scenerios so protocols are focused that way and we end up putting IVs into people that 99.9999999% of the time could be transported without the IV and have no adverse outcome.

I routinely have patients where I work now that if I was where I started out, would be transported BLS (all response unit ALS system) with the Medic Unit being cancelled, but here they get IV, O2 and EKG only because that's what the expectation is here. Almost all ambulances here are ALS, so I guess they figure, why not do something since you're already there.

The bulk of this would be the STEMI pt, the CVA pt, the multitrauma pt. Each of these could be handled by an EMT-IV. It's easy to obtain and transmit a 12 as a basic.

I disagree. Some of these patients could be handled at a lower level (assuming "IV" is comparable to "Intermediate"). However, from my experience as an EMT-I, treatment of cardiac related patients was Paramedic level. Also, if any of these particular patients were particularly bad, the additional treatment would be beyond the "I" scope of practice.

In order to keep money in EMS, we're going to need to transfer from mileage based billing to reimbursement by skill hours. No one's going to approve that with EMT-P education being what it is at the present.

Maybe your area is different, but where I'm at EMS billing is typically done as a base rate (dependent on care provided) plus an additional (nominal) charge for mileage.

The community outreach, working in MD offices, etc. aren't traditional EMS.

Right, and they aren't actually considered to be "Emergency Medical Services" in the first place either.

But the EMT/medic don't only do 911 prehospital txp. The field includes IFT, CCT, flight, and working in the ED. Most EMT-P programs don't prepare the student to function in these environments.

I'm not sure what "IFT" refers to, but working in the ED is not working "in the field". If most EMT-P programs don't prepare their students to work in these areas, then maybe it's because that's not the focus of initial paramedic training? Until recently, paramedics worked predominantly providing emergent pre-hospital medical care. So, the education focused on that and additional training was provided in order to work in those other clinical settings.

A real paramedic should have the education to be able to do CCT, flight, etc. They should be able to do more than just skills in the ED.

Well I guess I'm not a "real paramedic" then since I'm only "trained" to operate in the clinical setting that I only work in.

Nurses don't just work in the ED or on the floor. They specialze in all different types of specialties. Paramedics can do the same. The community outreach services would be one way the FD could see additional revenue from paramedics.

Yes it could be, but that doesn't necessarily mean that all paramedics nationwide need to be trained for this.

I wasn't saying to educate pts while on a call, but rather have a program where the FD sends interested medics around to pt's homes and help them manage their condition, and also to educate as to alternatives to the ED.

If that's what you were saying, then that wasn't clear. It came off as though you were saying a 911 response ambulance crew should be doing this.

[/quote]It's another way for a medic with a broken down body to get off the road, and to get off of shift work if they want. Real treat and release, or to direct txp by alternate means, won't come with our education as it stands currently. Nurses are doing this over the phone in Richmond, triaging pts and informing them of alternatives to EMS response and txp to an ED.

http://icma.org/en/Article/11568/Nur...in_Richmond_VA

Educated paramedics can do the same, whether it's while working at the 911 dispatch center, or on the road. It saves money. The board of supervisors and the bean counters like that. [/quote] What is "real treat and release"? As I already stated, I can do treat & release and alternate tx now.

As far as someone being able to do our job by just learning the skills, I'll reference NYS. Their EMT-CC, which I believe is the equivalent of an EMT-I elsewhere, can do all the skills a paramedic can, but needs to call OLMC for most of their meds and therapies. They're basically just information gatherers for the doctor. That's why anyone trained in a basic assessment and our psychomotor skills can do our job. The difference in education isn't all that great, when compared to what's necessary to practice as a paramedic elsewhere in the world.

I'm a little confused. You're stating that a EMT-CC or I is basically the same as an EMT-P and the training isn't that different to be a paramedic elsewhere in the world, but earlier you stated that US Paramedics couldn't work in other countries because our education was so poor.

Now, I can't speak to NYS training and certification, but from personal experience there is a huge difference in overall scope of practice, skills and education between NC EMT-I and PA EMT-P!

Some systems even have their paramedics call for everything. I believe L.A. is like that, but I could be wrong. NYC paramedics can't treat two simultaneous conditions at once. If they need to jump protocols, they need to call OLMC, then abandon the first protocol, and then go to the next one. I didn't realize how restricting that was until I left the system. Here, the protocols are more like guidelines. As long as you can justify your action, and are referencing a protocol (or several as the case may be), you're okay. For extraordinary care, you can still call OLMC. It seems to me the NYC REMSCO knows how inadequate our education is, and how the quality of medic can vary greatly from FDNY to the hospitals to the privates, and reflect that in their protocols and SOP's. If paramedics had a better education as a minimum standard, we wouldn't have this problem.

Is the problem one that can only be fixed by a degree program or is the real problem poor teachers and/or bureaucracy that allows substandard students to enter and/or graduate from the current programs and then not get weeded out at the medical command review level?

[FireMedic049]

No, but I don't feel that every psych pt needs to go to an ED, where they'll be billed (or the taxpayer will be billed) for an eval by the attending, the psychiatrist possibly, then another bill for BLS txp to a psych facility. That's plenty of waste, and part of the reason why our medical insurance premiums rise so much every year. I don't feel that all psych pts need to go to the ED any more than I feel the majority of our pts need to go to the ED. Getting the pt where they need to go is in their best interests, and indirectly saves us money as well.

I agree, but again, this isn't something that using degree paramedics as the entry level will solve.

In my area, EMS typically gets involved in most psych related incidents because the overall mental health services network lacks the ability to effectively respond to these situations. It takes too long to get a mental health worker to a scene to handle it that way. PD and/or EMS can't sit around waiting for them to get somebody there, so we (or the PD) usually take them to the hospital because there's no viable alternative currently. In some cases, they need medical clearance before being accepted for in-patient treatment, so they go to the ER.

[headoutdaplane]

Well I have been keeping up on this thread and I am just not seeing the need to make an AA degree mandatory for a Paramedic.
1. The examples that were given as being the realm of P's with degrees because of better understanding of A&P, are run every day somewhere in the states with the right decisions being made by non-degree 'P's.
2. I would agree that there are mills out there, program accreditation requirements should be more stringent.
3. testing should be made more difficult, really a 70% to pass is ridiculous.
4. Some of the issues that are being brought up should be left to other sectors of healthcare not EMS. If a person wants to be in public health let them go get a degree, PA, Nurse, or nurse practitioner, or even doc.
5. I spoke with my friend in Australia, and it doesn't sound like prehospital patient care results in any better patient outcomes in a country with much higher educational standards, in other words there is only so much we as prehospital providers can do.
6. All that said, if the idea is to create higher salaries by adding an arbitrary barrier to entry, I believe it would work.

[FFmedic60]

There are advanced practice paramedics these days, just as there are advanced practice nurses.

Nurse Practitioners and PAs are physician extenders which can require up to a Masters degree and a DEA number. They are afforded privileges no Paramedic in the US even comes close to nor does any education program for Paramedics even at the Bachelors level. Why even think about reinventing the wheel when you already have PAs and NPs? They already exist if you want to do that type of work. Prehospital medicine is a specialty which needs to be mastered at the basic BLS and ALS levels before trying to become "advanced".

Yes, Wake Co. EMS in NC comes to mind.

Wake County just gives a few Paramedics the privilege of riding around in a fly car to intubate and make decisions on which hospital to take the patient to. That way they do not have to worry about keeping all their Paramedics competent in all the skills Paramedics in other parts of the country do everyday. They may also do a few welfare checks which some FDs have already been doing for years. If you look at their protocols there is nothing any different in there that any decent FD/EMS couldn't do. RSI is not even that difficult to learn and be trusted with.

You mean like this?

http://www.co.sanmateo.ca.us/portal/...tcurrchannel=1

Determining if a person threatening suicide and that they need to go to a psych facility is not counseling.

EMS regardless of which service does it needs to get its act together and stay competent in the few skills and medications they do now. Being a Paramedic is not difficult and none of our FFs have had a problem passing the program or taking the NREMT. We are able to do what is necessary to get the patient to the hospital or declare them dead in the field instead of transporting a body. EMS and Paramedics don't need to be getting a big head at this time thinking they are the same as NPs or PAs. If you want to work in a hospital, become a nurse. Concentrate on prehospital medicine and get that right. Quit trying to be like another profession. I think that is just a cop out for not wanting to do the job as it is or attempt to make it better.

I don't think a degree is required if you have a decent medical director who gives you good protocols to follow and trusts you enough to certify you to function as a Paramedic. If the medical directors felt more education and a degree was necessary, they would have pushed for it a few decades ago.