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The National EMS Scope of Practice: An Exercise in Futility

I travel fairly extensively throughout the United States and interact with many EMS providers. In recent months, the conversation in EMS circles has always gotten around to the National EMS Scope of Practice Model. As the discussions unfold, one thing becomes painfully clear. EMS providers in the United States almost unanimously hate the proposed model. In fact, the only people I've met who like the model are the ones who worked on it. Even some of those will complain, privately, that the document aimed low and still missed in regard to the future needs of EMS in the United States.

I mean no disrespect for those who put many hours into the "Emergency Medical Services: The National Scope of Practice Model" is the final version, and it has been submitted to the National Highway Traffic Safety Administration (NHTSA) for approval. Those who worked on the document did the absolute best they could do. They are good and honorable people.

But, like any document that involves politics, consensus and compromise led to a document so impotent that horse-killing doses of Viagra won't even help. Many state EMS agencies have already warned that they don't plan to adopt the National Scope of Practice.

So it seems that EMS will remain in exactly the same state of flux it's in now. There will be even more variation in EMS levels between the states, which will make it harder for providers to move their certifications or licenses among states. It will make it more difficult to prepare textbooks that would address the various wants and needs of 50 states and who knows how many territories. There may be a trend away from the National Registry of EMTs, as each state stakes out its own scope of practice and eventually develops its own certification exam. And, worst of all, this document will relegate EMS to the status of a trade instead of a profession.

Although the problems with the National Scope of Practice are many, some certainly stand out. First, the document states precisely what psychomotor skills each of the various levels of EMS providers will, at a minimum, have. This is the sort of document you would expect to see for a trade. For example, what is the difference between the following requirements?

From the National EMS Scope of Practice:

The following are the minimum psychomotor skills of the AEMT:

* Airway and Breathing

* Insertion of airways that are NOT intended to be placed into the trachea

* Tracheobronchial suctioning of an already intubated patient

* Assessment

* Pharmacological Interventions

* Establish and maintain peripheral intravenous access

* Establish and maintain intraosseous access in a pediatric patient

* Administer (non-medicated) intravenous fluid therapy

* Administer sublingual nitroglycerine to a patient experiencing chest pain of suspected ischemic origin

* Administer subcutaneous or intramuscular epinephrine to a patient in anaphylaxis

* Administer glucagon to a hypoglycemic patient

* Administer intravenous D50 to a hypoglycemic patient

* Administer inhaled beta agonists to a patient experiencing difficulty breathing and wheezing

* Administer a narcotic antagonist to a patient suspected of narcotic overdose.

* Administer nitrous oxide for pain relief

From the National Welding Institute:

The welder will be able to:

* Shielded Metal Arc Welding

* Perform safety inspections of equipment and accessories.

* Make minor external repairs to equipment and accessories.

* Set up for shielded metal arc welding operations.

* Operate shielded metal arc welding equipment.

* Execute corrective actions to repair surface flaws on welds areas and base metals.

* Make fillet welds, all positions, on plain carbon steel or stainless steel plate using stainless steel electrodes.

* Make groove welds, all positions, on plain carbon steel or stainless steel using stainless steel electrodes.

* Make groove welds, all positions.

* Make fillet welds, all positions, on carbon steel pipe.

Look awfully similar? Which is a trade and which is a profession?

Now, look at the entire respiratory therapy scope of practice (compared with the 37-page National EMS Scope of Practice):

"The practice of respiratory care encompasses activities in: diagnostic evaluation, therapy, and education of the patient, family and public. These activities are supported by education, research and administration. Diagnostic activities include but are not limited to: (1) obtaining and analyzing physiological specimens; (2) interpreting physiological data; (3) performing tests and studies of the cardiopulmonary system; (4) performing neurophysiological studies; and (5) performing sleep disorder studies.

"Therapy includes but is not limited to application and monitoring of: (1) medical gases (excluding anesthetic gases) and environmental control systems; (2) mechanical ventilator support; (3) artificial airway care; (4) bronchopulmonary hygiene; (5) pharmacological agents related to respiratory care procedures; (6) cardiopulmonary rehabilitation; and (7) hemodynamic cardiovascular support.

"The focus of patient and family education activities is to promote knowledge of disease process, medical therapy and self help. Public education activities focus on the promotion of cardiopulmonary wellness."

In four years of medical school, I never saw a scope of practice paper for physicians that listed the various psychomotor skills a physician may need; the scope of practice documents for physicians and nurses are more global. The new EMS Scope of Practice document clearly puts EMS in the domain of a trade and not a profession. EMS needs a more global description of the profession. Then, local providers and educators, as directed by the respective medical directors, can establish what procedures and medications will be utilized in their respective EMS system.

The writers of the document go to great length to explain the difference between a scope of practice and a standard of care. Although that looks good on paper, a National Scope of Practice document becomes a de facto standard of care by default. Say, for example, a medical director wants AEMTs in their system to place adult IOs. Although the document does not forbid adult IOs at the AEMT level, it says AEMTs may, "Establish and maintain intraosseous access in a pediatric patient." This was specifically worded to exclude adult IOs for some reason. Somewhere, there is an attorney and a jury that will read this document as forbidding adult IOs, and the AEMT and the medical director will find themselves in quite a pickle.

The educational curriculum for the four levels of EMS providers is already underway. The National Association of EMS Educators (NAESME) has obtained the contract to develop the curriculum, and the University of Texas Southwestern Medical Center-School of Allied Health is charged with preparing the documents-on the basis of the new scope of practice model.

Perhaps the biggest disappointment in this document is the fact that there's no mandate for paramedics to hold a degree or for paramedic programs to be college-based. In a sell-out to the big fire departments, certificate programs for paramedics will be allowed. This will allow traveling paramedic programs to continue to crank out graduates and to provide a never-ending supply of eager paramedics willing to work for $8 an hour.

The future of EMS as a profession is based on education. A two-year associates degree should be the very minimum for paramedics. A lot can be gained from a college- or university-based program. As EMS education evolves, the resources of the college (e.g., library, media center, laboratories, cadaver labs, and so on) are invaluable. In addition, human patient simulators are becoming very important in EMS education. Each of these resources can cost in excess of $100,000. Most community "certificate" programs could never afford these. Like it or not, there is a big difference between college-based and community-based EMS education.

Well, I've wasted enough bandwidth on this. The document is already written. The curriculum is being developed. The states will take a skeptical attitude of "wait and see" before deciding that the National Scope of Practice is not for their state. And we'll be exactly where we were five years ago.


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