Over the last three years, New Orleans EMS has been among many municipal EMS and fire agencies that have felt the pressures of the COVID-19 pandemic. New Orleans made headlines early in the pandemic with Mardi Gras 2020 labeled as a potential super spreader event, public health officials pointed to the festival spawning as many as 50,000 cases.1
Since 2020, the city’s first responder attrition has worsened, leaving New Orleans EMS currently operating at 70% of their ideal field staff. At any point, the service may be deploying anywhere from four-to-seven of their own trucks per shift with supplemental help from a partnering private service. New Orleans EMS has prided themselves on being the only 911 medical response in Orleans Parish since being founded in 1947, meaning that their services they provide are necessary to keep the citizens and visitors of New Orleans safe and reduce the potential for loss of life.
Since the start of the pandemic, the agency’s primary focus has been to navigate and develop creative solutions to accommodate the high call volume and deliver the citizens of New Orleans the medical care they need in a timely manner. In early 2020, the agency developed and piloted its first ever basic life support units, allowing their EMTs to function autonomously with support from paramedic intercepts as needed.
Despite this, the continued hemorrhage of providers combined with the financial and time barriers of paramedic school, the city still found itself in a dire shortage of ALS resources. Enter the New Orleans EMS Advanced EMT program.
The goals of the Advanced EMT program are threefold:
- Continue to provide the citizens of New Orleans with ALS care,
- Reduce the stress on current paramedic providers,
- Provide EMTs with a way to advance their career.
Advanced EMTs in the state of Louisiana have a liberal scope, allowing medical directors to sign off on interventions and medication administration as they see fit. For New Orleans EMS, this allowed the implementation of Advanced EMTs to practice far closer to a paramedic scope of practice than an EMT’s as long as proper education is provided within the agency. For New Orleans EMS, that meant designing classes and in-services to train their AEMT providers to administer medications such as narcotics, antiemetics, some cardiac medications like nitroglycerin and epinephrine 1:10,000, sodium bicarbonate, and respiratory medications like steroids and magnesium sulfate.
With these advancements, the burden on paramedic providers is lessened since AEMT’s can handle acute respiratory distress, seizures, heat exhaustion, pain management, acute coronary syndrome, foreign airway obstructions and even the start of most cardiac arrests. Without the implementation of this scope, these calls would fall to BLS providers who would have to make the decision to either transport to the closest facility or request further ALS support on scene, increasing the demand placed on paramedics.
As for the agency’s BLS providers, departmental sponsored training developed in-house makes education significantly more accessible. This allows EMTs to become ALS providers at a minimal cost to them at a time when becoming an ALS provider might have otherwise been restricted by student loans or out of pocket expenses.
The Advanced EMT program launched September of 2022 after four clinicians took nine months to develop and propose the scope of practice, policies, and procedures while obtaining the required education. Alexis Paquette, Brendan Chase, Benjamin Griswold, and Tymarius Walton were recognized by the department for their dedication to improving public health and emergency service accessibility as well as providing outstanding BLS care throughout the pandemic all while obtaining various degrees of higher education.
With the support of the agency administration and field staff, when the pilot program officially went into effect September 15 they became the most progressive and autonomous Advanced EMTs in the State of Louisiana.2 They are limited by only advanced cardiac capabilities, sedation, blood administration, and intubation, meaning they are allowed to manage the majority of the ALS calls the service sees. With limited exceptions, paramedics typically only take over dynamic cardiac calls, excited delirium, and traumas requiring decompression or blood administration. All other ALS calls can be handled by AEMTs.
Since September, these four Advanced EMTs ran over 2,500 calls for service as primary providers, including 48 cardiac arrests as of June 2023. Of these 2,500 calls, care was turned over to an intercept paramedic only 2.3% of the time. With the success of the initial integration, the AEMT program has entered its next stages by refining the operational policies, modifying the scope of practice, and adding another four clinicians to the group with the anticipation to at least double the number of AEMT units by the end of the year.
With the scope of practice and skill level so closely approaching those of a paramedic, NOEMS has recognized and developed a targeted education and field training process for AEMTs. The plan is to produce competent ALS providers without compromising the care citizens and visitors of New Orleans receive. This means Advanced EMTs for New Orleans EMS will have to meet a higher standard of qualifications to practice at their level in addition to the state’s requirements.
This includes practicing as a BLS employee to develop a better understanding for operations and patient care while simultaneously maintaining good clinical and operational standing. Once those are met, they will have to attend in-services required by the state and the agency’s medical directors for skills and operations. These include an in-house cardiology and pharmacology review, skills specific to the ALS level such as using Magill forceps, and acquiring their ACLS, PALS, AMLS, PHTLS, and EPC certifications. Once they have completed the educational requirements, they will go through a mentorship field training period that mirrors what new paramedics are required to do. By doing this, NOEMS provides its AEMTs with a solid foundation and educational background combined with real world experience, without compromising personal time or compensation.
New Orleans EMS recognizes that access to education is only part of the issue resulting in the national loss of providers over the last three years. Pay increases, compassion fatigue, burn out and concerns for provider wellbeing have all been a top priority administration has been addressing. However, deploying and utilizing a once untapped ALS resource within the agency is one step closer to bridge the gap in providing services the community relies on. The utilization of Advanced EMTs strives to improve the emergency medical service field in gaining the recognition prehospital providers deserve within the healthcare industry.
EMTs, Advanced EMTs, and paramedics are critical structures within a patient’s healthcare team and their experiences prove time again they are deserving of that recognition. Over the last 10 months, the original four Advanced EMTs have each had hundreds of opportunities to prove the success of this program and their capabilities as ALS providers. Following are formative stories from earlier in their experience, hopefully exemplifying the type of ALS care these providers are capable of handling.
Alexis Paquette
A few shifts into my field training process, my field training officer and I responded to a cardiac arrest for an approximately 40-year-old woman. When we arrived on scene, we found her in the bathroom and her family stated it was a witnessed arrest and after she woke up she having trouble breathing. It was relayed to us as we repositioned her that the patient has severe asthma with a history of multiple intubations.
As we started with CPR in our traditional pit-crew fashion and applying the LUCAS device, our first rhythm check revealed she was asystole. As an Advanced EMT, I had been able to obtain intraosseous access, administered cardiac epinephrine in a concentration of 1:10,000 as the fire department maintained a BLS airway. I then inserted an laryngeal mask airway (LMA) and attached end-tidal monitoring to confirm placement, which had a correlating end-tidal reading of 99mmHg.
On assessing lung sounds, the patient was diminished with wheezing heard bilaterally. With the clinical findings and patient history, I ordered for an inline DuoNeb treatment to be administered and gave 2 mg of Magnesium Sulfate hung in a 250mL bag of D5 over 10 minutes. Myself, my FTO and the fire department continued with routine ACLS treatment and on our fourth rhythm check, the patient was noted to be in a narrow complex, organized sinus rate of 100 bpm. There was no correlating pulses on assessment and so CPR was resumed. I then ordered for my partner to draw up a “push dose epi” (epinephrine 1:100,000) as I suspected to have a return of circulation on the next rhythm check.
On reassessment, the patient had a corresponding pulse with a heart rate of 120 bpm. Their initial pressure was hypotensive and the patient received 1mL of the push dose epinephrine which helped the patient stabilize enough to remove them from the home. Once to the back of the truck, the patient’s heart rate was noted to have remained tachycardic and the patient sustained a normotensive blood pressure. For the remainder of the transport, the patient maintained her vitals without rearresting.
Everything from time of contact to offload at the hospital was within the NOEMS AEMT scope of practice. While my paramedic FTO was available and on scene, I was able to utilize my skills and clinical judgment to provide the patient with the best possible outcome, all within my scope of practice. This real-world experience proved that not only will AEMTs be successful for NOEMS, but this caliber of medical care could be applied across other agencies, rural, urban or otherwise. From cardiac arrests to hip fractures, the AEMT scope of practice can allow communities to feel safer knowing their providers can offer them competent care in a time of crisis.
Brendan Chase
On my first night clear from the FTO process, my EMT partner and I responded to a report of a seizure. Finally equipped with midazolam and the knowledge how to use it, I felt far more capable than when I responded to seizures at the BLS level in the height of COVID-19. As I was snapping on my gloves, I figured it would be a “routine” seizure call.
Much to my surprise, the patient had no seizure history, was 30 weeks pregnant with a blood pressure of 190/palp. Instead of immediately grabbing my narcotics pouch, I administered magnesium sulfate IM that ultimately brought the eclamptic seizure under control. The call burned into my memory as one of the first great tests of critical thinking on the ALS level and left me thankful for our expanded scope of practice and additional in-house education.
Benjamin Griswold
I remember being very nervous for my first shift out of the FTO process. We had all worked very hard to build the protocols and get this program off of the ground. The rubber was finally meeting the road and I was realizing that I was going to be the primary ALS care provider for the first time.
My EMT partner and I went on our first two calls that were fairly low acuity. However, the next call came out as severe respiratory distress and my adrenaline started pumping. The patient was struggling to breathe and had a history of COPD and CHF. I realized that I was now the one that was going to have to differentiate which was afflicting the patient today and then would have to proceed down the appropriate treatment path.
The patient had a clear “shark fin” EtCO2 waveform, bilateral wheezes, and was normotensive, leading me to proceed down the COPD treatment path. The patient only slightly improved with a DuoNeb, so I proceeded with CPAP and steroids with some improvement. At this point I am getting nervous as I am worried the patient is starting to become tired. I made the decision to start a MagSulfate drip and the patient began to improve dramatically.
We had gone over this course of treatment in class, but I had not gone this far down the treatment path during my FTO phase. I remember we transported the patient to a smaller hospital that was close by and on our arrival the junior physician remarked that they did not know paramedics could do Mag drips, but that they were impressed. I informed them I was actually an Advanced EMT, but yes it was in our scope of practice. The doctor smiled and thanked me, and I knew that all the training we went through was going to truly make a difference for the citizens of New Orleans.
Tymarius Walton
After completing the newly established Advanced EMT field training process, I was asked to remain on the night shift for a weekend before transitioning back to days. A few hours into my first shift as a cleared AEMT, my partner and I were dispatched to a call for an elderly female complaining of shortness of breath.
Upon arrival, the patient was slumped over gasping for air, rapidly approaching respiratory arrest. This required quick thinking and maneuvering of the patient so that I could immediately take over her airway and ventilation via BVM with 15LPM of supplemental oxygen. I initiated cardiac monitoring which revealed the patient to be in a sinus-rhythm at 130 bpm and correlating pulse oximetry at 64%.
I noted the patient was hypertensive and hypercapnic. Lung sounds revealed rales bilaterally, confirming my suspicions of CHF. In my short transport to the ED, I was able to obtain IV access and continue monitoring her heart for any rhythm abnormalities. With continued control of her airways, I was able to increase her oxygen saturation to 100% and her mental status improved from a GCS of 9 to 12. The interventions provided helped reverse the hypoxia and prevented the patient from entering cardiopulmonary arrest. This is just one of the many scenarios in which AEMTs can excel with the appropriate education and training.
Once just an idea tossed around after a shift, the New Orleans EMS Advanced EMT program has grown into a tangible benefit for the citizens and visitors of the city. While New Orleans EMS continues to face the adversities exacerbated by the pandemic, the AEMT program stands to manage the loss of ALS resources from the agency. The statistics presented in the attached graphic illustrate the high acuity work just 4 AEMTs can handle (Graphic 1). With EMS staffing levels across the nation in a truly dire state, AEMTs are an underutilized provider level that offers tremendous possibilities.
References
1. Emily Woodruff. (2021). Mardi Gras 2020 spawns up to 50k coronavirus cases, likely from a single source, study says. nola.com.
2. While not the first to introduce the level of care, other agencies require a paramedic to be present for an AEMT to operate at the ALS level.
