Airway & Respiratory, Columns, Patient Care

Bledsoe’s EMS Scope of Practice Model

Editor s note: For details on the National EMS Scope of Practice Model proposed by a group of EMS leaders (selected by the National Association of State EMS Directors and with funding from NHTSA), read Educators Wrestle with Proposed Scope of Practice Model, October 2004 Insider and the Priority Traffic article WANTED: Input on Proposed Provider Names & Scopes of Practice, November 2004 JEMS.

Visit www.emsscopeofpractice.orgto review the model and submit comments to the group by January 2005.

The new EMS Scope of Practice document is an interesting and somewhat controversial plan for the future of EMS in the United States. I have to admit that I don’t totally agree with all facets of it but at least we are looking in the right direction. However, as I travel this great land, I have encountered a good number of people and organizations that oppose the National EMS Scope of Practice model. The reasons vary. But, regardless of the politics, we must come up with EMS provider levels that are based on a preponderance of the scientific data. I’ll tell you what I would do I’ll call it Bledsoe’s EMS Scope of Practice Model. Now, this is not something I just came up with. This all comes from a few lectures I gave back in the 1990s at the Texas EMS Conferences. I just polished it up to incorporate some of the concepts and ideas in the new National EMS Scope of Practice proposal.

Skills and knowledge levels

Emergency Medical Responder (EMR) Emergency Medical Responders (EMRs) would correspond to the current first responder level. Providers would be AED and AED-Instructor certified, and BLS and BLS-Instructor certified. Public safety and similar personnel would receive additional education in weapons of mass destruction and homeland security. They would be able to apply AEDs, administer oxygen, use basic airway adjuncts and be able to administer medications by auto-injector (e.g., epinephrine and bioterrorism antidotes). Education: Approximately 80 hours.

Emergency Medical Technician (EMT) This level would be called simply Emergency Medical Technician (EMT) and not EMT-Basic or EMT-Ambulance as in times past. The EMT would be the minimal level to work on an EMS transport vehicle. The new EMT would have the current EMT skills and knowledge. In addition, the EMT would be able to place a mechanical airway such as a CombiTube, LMA or similar airway (not an endotracheal tube). They would be certified in AED use and instruction. They could administer aspirin, nebulized bronchodilators, nitrous oxide/oxygen, nitroglycerin, epinephrine 1:1,000 and glucagon. In addition, they could help patients with patient-administered medications. They should be able to start and maintain IV lines, manage rate and volume-controlled ventilators, verify and monitor endotracheal tubes, use waveform capnography, perform pulse oximetry and blood glucose monitoring. Education: Approximately 200 hours.

Vocational Paramedic (VP) or Technical Paramedic (TP) The Vocational or Technical Paramedic would be called a paramedic but would have skills primarily designed for the urban or suburban setting. The vocational paramedic would carry enough medications to run a cardiac arrest for 15 minutes. They would be able to intubate and use alternative airways. They would be able to administer first-round ACLS drugs, treat pain with fentanyl or morphine, give nebulized bronchodilators, treat CHF with nitrates and diuretics, start IVs and IOs, treat ACS with aspirin, nitrates, morphine, and such. They would have limited 12-lead ECG skills; instead of independent interpretation, they would rely on the computer or medical control for interpretation. Waveform capnography would be a standard of care. This level is ideal for dual or multiple-mission services where the paramedic must also serve as a firefighter, police officer or similar responsibility. Education: 800 hours.

Licensed or Professional Paramedic (LP) The Licensed or Professional Paramedic would be also called a paramedic. This role would be for rural and similar settings where transport times exceed 15 minutes. Also, these providers would be ideal for services that are dedicated purely to EMS. They would have all current paramedic skills including RSI, use of pressors, ability to administer fibrinolytic therapy, ability to manage the difficult airway, decompressing chests, interpreting complex 12-lead ECGs, and would carry considerably more medications than other providers, depending on transport time and other factors. They would have some independent practice and preventative medicine skills (e.g., feeding tube, Foley catheter replacement, immunizations). They would be the senior EMS provider on most EMS scenes. Education: Associate s degree.

Critical Care Paramedic (CCP) The Critical Care Paramedic would be a Professional Paramedic with at least four years of field experience who has taken a critical care course similar to nursing (not the two-week variety). They would be able to handle the full gamut of critical care transport including: airway and vent management, complicated medication therapies, central venous access, blood administration, interpretation of common lab and diagnostic studies, and other advanced skills typically associated with critical care medicine. All flight paramedics would need this level of certification. Education: Associate s degree with additional year of CCT education.

Specialty Paramedic The Specialty Paramedic would be a Professional Paramedic with additional education in a given area. These areas would include: industrial medicine, sports medicine, public health, tactical medicine, military medicine (Special Forces) and similar fields. Industrial medicine specialty paramedics would receive education related to their industry (e.g., off-shore, chemical plants, large buildings). Specialized skills might include suturing of simple wounds, treatment of eye injuries and removal of corneal and conjunctival foreign bodies and similar skills. They would also receive additional education in safety and accident prevention. Advance military medics (Special Forces, Air Force PJs, Air Force Independent Duty Corpsmen) would be a type of specialty medic certified in both the military and civilian arenas. The specialty would involve great emphasis on battlefield medicine but also on areas that are considerably different from civilian paramedics (e.g., emergency dental care, prolonged patient care, emergency veterinary care and independent duty field care). Sports medicine medics would have additional training in prevention of athletic injuries (e.g., taping, splinting), on-field emergency care, and would be able to make decisions about returning a player to the game. Tactical medics would receive additional education on prolonged care, specialized trauma care and similar education. Education: Associate s degree (or similar) and additional education in area of specialization.

Independent Practice Paramedic (IPP) The Independent Practice Paramedic is a Licensed or Professional Paramedic who has completed an Advanced Practice Paramedic or Independent Practice Paramedic program. This would somewhat parallel the Physician s Assistant model. This level of provider could function as a high-level field practitioner providing treat-and-release care (e.g., simple sutures, G-tube replacement, tracheostomy changes, Foley changes, homebound IV therapy, dislocation reductions, nail trephination, use of local anesthesia and similar skills) for selected cases. They could be educated as a rural independent practitioner with additional basic general medicine skills (e.g., simple diagnosis and treatment, suturing, abscess I&D) essentially to provide care for 24 48 hours for simple cases until the patient could get to a physician. Education: Bachelor s degree in EMS in area of specialization.

There, that s it, fairly simple. All of this should be based on the preponderance of current scientific evidence such as the Ontario Prehospital ALS (OPALS) study and other current research. If prehospital endotracheal intubation continues to show to be problematic, pull it back to the Professional Paramedic level and above, where there would be more experience and more opportunity to perform the procedure. We should no longer think of Emergency Medical Responders and Emergency Medical Technicians as being basic life support providers; that concept went out years ago. All levels of EMS providers are partners on the same continuum of care. The more severe the emergency, the more EMS provider levels should be educated to manage it. The less severe (or more infrequent) the emergency or problem, the fewer EMS providers will be educated to manage it. This follows the old supply-and-demand theory.

Although these levels should be nationally standardized, they should be seen as minimum standards. Each state and geographic region should still be able to change the mission and scope of practice to meet the needs of the population at risk. There s a vast difference in the patient population and the practice of a paramedic working in Brooklyn, N.Y., when compared with that of a paramedic in the frontier Texas town of Terlingua. Local or regional medical control should be customized to the system and the population at risk.

In our society, we don’t need the highest level of care provider on each and every emergency run (although we think we do). We must take into consideration such things as transport time, other responsibilities, patient population, quality of first responders, available resources, funding and similar information to determine what level of care provider should be available. But, as a rule of thumb, the farther an EMS provider is from a hospital, the greater should be their education, skills repertoire and formulary.

That’s my story, and I’m sticking to it. What are your thoughts?