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The 21st Century Paramedic


Several years ago, I spoke at a conference in Harrogate—near the Yorkshire Dales in England. It was a great conference and trip—seeing how England provides EMS. While there, I visited with faculty members from several innovative paramedic education programs. Two of these, the University of Hertfordshire and the University of Plymouth, had developed paramedic practitioner programs for the U.K. These programs were primarily designed to address the health-care needs of those in the community who don’t require hospital care but are unable to go to their general practitioner. This new level of provider seemed to address a gap in the U.K.'s health-care system.

Now, in the U.S., we're starting to see similar issues in our health-care "system." A recent report from the American College of Emergency Physicians (ACEP) found that the average length of stay for most U.S. emergency department (ED) patients now exceeds four hours. This is certainly an added strain on an already overtaxed EMS system. In the greater Las Vegas area, where I primarily practice, we're seeing an increased number of non-emergent patients arriving by EMS at our ED. I'm sure the same thing is occurring in other parts of the country. This begs the question: Do these patients have to go to the ED, or can they be safely treated and released or safely treated and transported to a lower-level facility?

The health-care reform package recently enacted by our Congress is vague in terms of how it will address ED overcrowding and the EMS system in general. The vision for the future of U.S. health care is murky at best. Our government hasn’t yet addressed the fundamental ethical issue as to whether health care in our country is a right or a privilege. If health care is a right, then the government should fund it. If it’s a privilege, then the user should fund it. The current model is a bastardization of both: The user primarily funds the costs, and the paying user often pays more to cover the health-care costs of the non-paying users (of which there are many). The government forces hospitals and EDs, primarily through numerous unfunded mandates, to provide care regardless of one's ability to pay. Why does the government not place the same mandates on dentists, chiropractors, psychologists, lawyers and interior decorators? The U.S. health-care system is in a vicious cycle that will soon fail.
It's time to think outside of the box. Damn the lawyers! We need to do something different. Perhaps we need to look at our British colleagues, as well as those in South Africa, and embrace and develop an accredited and validated form of the paramedic practitioner program. My good friend and colleague, Brent Myers, MD, MPH, FACEP, is already doing similar things in Wake County, North Carolina with their Advanced Practice Paramedics program. It can be done.

I feel it’s time for a true paradigm shift in paramedic education. For many years, we've emphasized treatment of the patient's primary injury with little regard for the secondary injury and the subsequent needs of the patient following delivery to the hospital ED. An expanding and evolving body of literature has clearly demonstrated that prehospital care does not significantly affect the primary injury (except through injury prevention). But, the same body of literature has shown that we have the potential to significantly affect secondary injury. At the most fundamental level, this is what induced therapeutic hypothermia and similar strategies are all about. This proposed paramedic practitioner model would fit well into this new model of paramedic education.

However, the Achilles heel of EMS—education—again comes into play. Any attempt to increase the knowledge and skills level of EMS personnel is often met with a pushback from the EMS community (or those in charge of the EMS community). As things currently stand in the U.S., EMS education is among the lowest when compared to all other allied health programs. In order for the paramedic practitioner program to work, we have to enhance and support the current educational programs. This means that these higher-level programs will almost have to be university- or college-based, and the length of such courses must increase.

The other rate-limiting step in this scenario is reimbursement. In our "customer pays" EMS system, there isn’t a reimbursement method for skills and practices that don't result in a patient transport to the hospital. Perhaps the proposed paramedic practitioner fits at the level of mid-level practitioner, such as physician's assistants and nurse practitioners. But, at present, there’s no scheme or system for funding this level of care by paramedics. Systems, such as Wake County, are primarily government-funded operations and can afford to do this if the community and local government leaders make the necessary financial commitment. However, most of the U.S.—especially rural areas where paramedic practitioners are sorely needed—EMS is often provided by private companies or volunteer agencies. Most of these are already operating in the red and adding unreimbursed paramedic practitioners might spell their doom.

I'll be the first to admit that this month's column has largely been an academic discussion. However, we're now approaching the end of 2010, and we're 10 years into the new millennium. Still, we’re unsure as to where the future of EMS will be. Certainly, the Agenda for the Future document was innovative and forward-looking. However, I believe it's time to look even beyond that. The expansion of the specialized paramedic in such areas as critical care, industrial care and similar endeavors has demonstrated that paramedics are uniquely positioned to play a greater role in health care. Perhaps it's time for those who are charge of guiding the future of EMS (whoever the heck that is) to establish a task force or similar course of study to investigate the feasibility and utility of paramedic practitioners in the evolving U.S. health-care system. As our colleagues in the U.K. and South Africa will attest, the time may have come.


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