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A Missing Link: How the new level of Advanced Practice Paramedic would fill the gap

Medical directors must often trust supervisors who exemplify the Peter Principleƒthose who advance to their highest level of competency and are then promoted to and remain at a level at which they're incompetent. Meanwhile, true leaders within their systems are being held back.

Some medical directors are impeding advancement of their systems by delaying implementation of certain skills, procedures or processes, thinking„I can't let some paramedics provide the treatment unless everyone is trained. So although paramedicsƒcurrently the highest level of„EMS licensureƒare initiating progressive interventions in some systems, neither comprehensive core patient care nor professional needs are really being addressed.

Many systems are functioning as they were originally designed 20 years ago. Some systems have hundreds of paramedics. Street-level providers and medical directors can identify those with advanced knowledge and skills, but there's no valid way to have them identify themselves, or for the system to reward them for their accomplishments. Many paramedics are standing around scenes holding IV bags, while others are cognitive ˙machinesÓ making all of the decisions and assuming patient-care responsibility for the same title, pay and recognition.

The Need for a Career Ladder

Using the principle of the lowest common denominator is holding back our systems. Fundamentally, there's no way to separate the few from the masses, the best and the brightest, the cognitive leaders from the average, and to allow these few to work with medical directors to lead EMS systems into the future.

There's no„EMS career ladder. Paramedics aren't staying in the profession, with many leaving the field to find more fulfilling and higher paying health-care work. Many of these paramedics have the affective skills to assess and treat patients from a physiological approach and have furthered their education beyond entry levelƒbecoming the ˙go-toÓ guys.

When we adopt new technologies, many providers learn by the trial-and-error method. There are no field-level experts to teach the masses on the basis of their experiences with these technologies. Research is being accomplished by physicians, not paramedics. Patients are assessed, treated and released, often by the crew that arrived and not by paramedics with advanced assessment skills.

The Fundamentals of APP

During development of the National EMS Scope of Practice, a level called APP (Advanced Practice Paramedic) was introduced to the nation. A great concept: Paramedics with advanced clinical competencies, further EMS-related education, and permission to provide certain care under medical direction. The APP level would be an extension of medical direction, a level needed in„EMS.

After national review, without being fully understood and vetted, the level was dropped from the Scope of Practice. It was a concept introduced before its time. Misunderstood, the APP concept met an early death. But times have changed. There's a way to define this new certification, and only youƒthe best paramedicsƒcan chart your own course.

An APP would extend the medical director's abilities.„EMS system research and effectiveness would be their purview. When new interventions are under consideration, the APPs would be the first to introduce them by cleaning up the bugs, teaching providers on scene and adapting the practice system wide.

On arrival, other paramedics would yield the cognitive responsibility for the patient to APPs. The career of APPs would be inhibited only by their own ability to succeed. Their specific scope of practice could vary from system to system depending upon local needs.

Implementing APP

This level wouldn't require unique licensure. It would be a specialty certificationƒearned through continuing education, advanced competencies and clinical requirements. It would require paramedic experience and endorsements as part of the certification process.

It wouldn't be inclusive but exclusive. It's not for everyoneƒonly those who have the ability to excel and the desire to serve.

At the 2008 EMS Today Conference in March, I will present a lecture on this new concept. I encourage you to attend and begin the process of creating this specialty certification sorely needed in our profession. There's a credible way to make this happen and develop it into what we need to better serve our patients, advance ourselves and improve our„EMS systems. Come join me in an exploration of how to implement APPs nationwide.

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