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Efforts are underway to come up with new titles for those who work in the emergency medical service profession. The new effort is called The National EMS Scope of Practice Model.
What is a “scope of practice”? Essentially, a scope of practice is a set of skills (intubation, starting IV, taking a blood pressure, etc.) that a state legally allows to you perform and not perform under your license or certification. Usually, the range of skills is established in a state law, statute, rule or regulation.
In 1996, the EMS Agenda for the Future identified at least 44 different levels of EMS provider certifications in the United States. It is highly likely that the number has increased since 1996. For example, as an EMT, in one state you may be allowed to defibrillate with an AED, but in another state, you may be not. The National EMS Scope of Practice Model is an attempt to provide a consistent definition on a national level of titles for EMS providers and what set of skills each provider level can do. Because states have the final say on authorization of medical licenses or certifications, it is each state’s decision whether to accept whatever comes of the effort to define new titles and what set of skills the EMS provider can perform.
How does this affect you? Regardless of whether you are an EMT, paramedic, administrator, educator or medical director, you have a chance to have input on the final document. Go to www.emsscopeofpractice.org, obtain a copy of the EMS SOP Model draft, read it, and if you want to comment, the website has instructions on how to submit your comments. But do not delay; comments are due Jan. 30.
What is driving this effort, how will you be affected and why would you want a say in the matter?
It all started in 2000, when the National Highway Traffic Safety Administration (NHTSA) and the Health Resources and Services Administration (HRSA) created a consensus-based document called, “National EMS Education Agenda for the Future: A Systems Approach.” The purpose of creating this agenda was multi-faceted. First, EMS provider levels vary from state to state. One state may call an EMT who is trained and licensed to start IVs an EMT-I, while another state calls that person an EMT-IV. Also, skills that are currently performed by EMTs and paramedics are determined by the national standard curriculum, instead of the medical needs of the community. This is especially true in rural communities, where paramedics could be more beneficial in health-related issues since they may be the highest medical licensees for miles.
Another reason is that the education of EMTs and paramedics in many cases was based on what educators thought the students needed to know, rather than on any data, research or patient outcomes. Finally, the agenda was created because there is no true career ladder for those who work in the EMS profession. The proposed Scope of Practice Model creates a new level of the current paramedic level.
The National EMS Scope of Practice Model has been in the works for over a year. The project is being managed by the National Association of State EMS Directors and the National Council of State EMS Training Coordinators. The International Association of Fire Fighters (IAFF) and the International Association of Fire Chiefs (IAFC), EMS professional-interest organizations and federal agencies have been meeting to come up with draft recommendations. Here are some of titles and skills levels for which they are looking for comments:
- Emergency Medical Responder (EMR). This is more closely associated with the current title of Medical First Responder. This title would perform basic lifesaving procedures for critical patients on scenes while waiting for additional EMS response. This title would not typically transport a patient to a hospital. This title would be allowed to use AEDs, apply oxygen through a bag-valve mask, suction, use oral and nasal airways, do basic assessment skills, use auto-injectors for themselves or another emergency person, and do rapid extrication.
- The next level in the recommendation is Emergency Medical Technician (EMT). The EMT’s skills would focus on acute management and transportation of critical patients either on a scene or in an ambulance enroute to a health-care facility. The EMT would be allowed to use pulse oximetry, do blood glucose monitoring, use multi-lumen airways, assist patients with physician-prescribed or over-the-counter medications, administer some medications such as nitroglycerin and epinephrine for an anaphylactic reaction, IV maintenance, ET confirmation, and rate- and volume-controlled automatic ventilators.
- The next level would be Paramedic. This is virtually the same level of skills now associated with the paramedic title, which includes endotracheal intubation, cricothyrotomy, pleural decompression, IVs and intraosseous insertion, administration of medications, cardioversion, manual defibrillation and transcutaneous pacing
- The biggest change that is in the draft document is the title of Advanced Practice Paramedic (APP). This level is designed to reduce morbidity and mortality of patients associated with critical, emergent and lower-acuity medical and traumatic conditions. This set of skills would include advanced assessment skills and allow the provider to release or redirect patients without transportation to an emergency room. This set of skills would best be utilized in remote areas where there is a limited EMS system and/or hospital system. The APP would allow rapid sequence intubation, surgical cricothyrotomy, central venous access, blood product administration, local anesthesia, anterior packing for nose bleeds, dislocation reduction, wound closure and urinary catheterization.
The Advanced Practice Paramedic does not currently exist in any EMS system in the country. However, we must consider that about 77 million baby boomers are about to retire and the infrastructure of the health care system has been undermined by cuts made throughout the 1990s as health systems and hospitals closed, nursing shortages continued and hospitals diverted patients. APP is an attempt to create a provider who can straddle the need of having someone that can handle low-acuity patients and find them access into the health care system from points other than the emergency room and also having advanced skills for the sickest patients. Most systems wouldn’t need more than 5% to 10% of their paramedic workforce to be trained to this level. When you look at the skill set of these providers, you will see they are geared to the older, more experienced medics who have a great deal of field practice and a complete understanding of the health care system.
Whatever comes out of the whole process, the bottom line is that the patients do not care what title you have. All they care about is that you show up and take care of their medical emergencies.
USFA Online Course Prepares EMS Responders To Operate at Multiple-Casualty Incidents
Michael D. Brown, Under Secretary of the U.S. Department of Homeland Security for Emergency Preparedness and Response, has announced a new online course designed to assist EMS personnel to respond more effectively when faced with a multiple-casualty incident (MCI). The new independent study course, “EMS Operations at Multi-Casualty Incidents,” is a four-hour, web-based course that addresses preparedness planning; management of the incident; safe and efficient triage, treatment and transportation of patients; and the de-escalation of the response. It is not intended to provide detailed steps in the care of patients.
Upon successful completion of this course, the participant/student will be able to:
- Describe the characteristics of multiple-casualty incidents.
- Describe the types and indicators of chemical, biological, radiological, nuclear or explosive (CBRNE) agents.
- Describe the steps of responding to a multiple-casualty incident, including preparedness planning, triage, treatment, transportation and incident demobilization.
- Describe the purpose of triage and how to perform it.
- Describe the purpose of decontamination and the resources required to perform it.
- Describe specialized medical treatment that can be administered to victims of CBRNE incidents.
EMS experts from across the country worked with training specialists at FEMA’s U.S. Fire Administration (USFA) to develop this course, which can be found on USFA’s Virtual Campus at www.training.fema.gov. The USFA has many other training programs, both online and classroom-based, that are designed to assist emergency responders in becoming better prepared for all types of emergencies. Information on these training programs and other USFA initiatives and publications can be found at www.usfa.fema.gov.
Gary Ludwig, MS, EMT-P, a Firehouse® contributing editor, is the chief of Special Operations for Jefferson County, MO. He retired in 2001 as the chief paramedic for the St. Louis Fire Department after serving the City of St. Louis for 25 years. He is also vice chairman of the EMS Section of the International Association of Fire Chiefs (IAFC). He is a frequent speaker at EMS and fire conferences nationally and internationally, and is on the faculty of three colleges. Ludwig has a master’s degree in management and business and a bachelor’s degree in business administration, and is a licensed paramedic. He also operates The Ludwig Group, a professional consulting firm. He can be reached at 636-789-5660 or via www.garyludwig.com.