National Scope of Practice Model

[EFD840]

This is probably a hornet's nest, but I'm curious and I've just got to ask...

Since the draft came out, I've seen a lot of people screaming gloom and doom for EMS (particularly volunteer EMS) if the National Scope of Practice Model is adopted.

For background, I'm NREMT-B in Alabama and the EMT scope of practice is almost an identical model of our scope as it exists now (just got dual-lumen airways last month). with maybe a little expansion in the epi/nitro/beta agonist area. All in all, at my level it seems to be mostly a wash. My question to my fellow basics is: do you see it as much of a change in the scope of practice for your state?

I don't have the knowledge to comment on the changes at the Paramedic level so I my question to the ALS crowd is this: Do you see it as a big deal at your level?

[Weruj1]

I havent read that much about it past them wanting to really define the levels of care .....I am not sure about the rest .......is there a place we can read the draft on line ?

[EMTfarmer]

National Scope of Practice (http://emsscopeofpractice.org/)

[Weruj1]

thanks mucho !

[WTFD10]

The EMT seems pretty close to the Ohio Scope of Practice (http://www.ems.ohio.gov/Education/EMS%20Scope%20of%20Practice0904.pdf)for Basics. Currently we are allowed intubation for pulseless & apenic, so the change to Combi-Tubes would be the major difference.

Question for the Paramedics on here: Isn't nitro administration contraindicated for a certain type of MI? Without cardiac monitoring, seems like nitro administration by EMTs could get a little dicey.

Overall, Here in Ohio I don't see what the huge changes to FR & Basic are that will cause vollies such problems. It's not much different than what we already have here. In other states it may be a huge change but I think it will be for the better overall.

[LeuitEFDems]

It will have big changes in Mass. The state currently uses the DOT-'99 for basic and paramedic, but they use the DOT-'85 (yes 1985...not a typo) for intermediates, which I currently hold the postion of, going through medic school. For all the classroom time we have, we are only allowed to start IV's of NS and intubate with ETT, or combi-tubes, no meds, no glucose scans, no monitoring as in the DOT-99.

[firefighterbeau]

The problems we see here in ND are the hours of training, we already have EMT-B's that have trouble with getting the required number of hours. We currently have provisions for combi-tube and nebulizor, but if IV and Intubation were to be added that would be more than our EMT's could handle result a drop in EMT's the a drop in squads. In addition many would not get the amount of practice, and real patients to keep the skills up properly. If this becomes the national standard i have heard ND will go to its own certification and cut out the NREMT's, working exactly the opposite of what this scope of practice it striving for. And i have heard from some around the state they wouldn't mind that, they feel the NREMT's isn't doing a good job.

[Weruj1]

Question for the Paramedics on here: Isn't nitro administration contraindicated for a certain type of MI? Without cardiac monitoring, seems like nitro administration by EMTs could get a little dicey. ......yes it can .........if the patient is having an MI that involves right sided heart failure/clot/blockage, then the nitro will have a negative effect due to dilation when you really need to be giving IV fluids, this is of course the condensed version. I personally like what good ol' Doc Morphine does and gives the EMT-B's the ASA.

[AKflightmedic]

Just to follow up on the NTG for right sided involvement. This type of pt usually has a low BP since this is a fluid problem. Therefore, NTG would be contraindicated as usual when BP systolic is less than 100.

As for the Scope of Practice model, I heard the committee recieved thousands of responses. I am glad people took the time to voice their opinions. Now we wait and see what happens. Personally, I disagree with a lot of it due to the training hours increase. I think the rural states and areas will suffer a great loss. I like the theory but some of the parts need a lot of clarification.

[pfd3501]

is it just me, or does the intermediate level (such as practiced in Ohio) is being eliminated?

[EFD840]

First, thanks for the responses! As I said in my first post, I don't see it having much impact here but it sounds like there will be big implications in other states.

pfd3501, Alabama got rid of intermediates a couple of years ago. Current intermediates have a way to stay credentialed and practice at that level but there are no more classes being conducted.

[EMTfarmer]

There are four levels in the new proposals:

Emergency Medical Responder
Emergency Medical Technician
Paramedic
Advanced Practice Paramedic

I had seen some proposed education requirements for the 4 levels but for some reason can't find them right now. Here in SD we have the same concerns expressed by firefighterbeau. Of the services that serve the perimeters of our coverage area, they have 10, 4 & 5 EMTs and a service that shut down due to lack of EMTs. The last agency is making an attempt to reinstate their service. While we are fortunate to have 23 EMTs in our service, we end up providing mutual aid to some of the services that border ours. In some circumstances it is nearly 30 miles one way to reach the farthest point in our coverage area. This may not be seem bad for my western friends and neighbors but it seems like an eternity when responding to a call for those of us in the eastern end of SD. I am unsure how many of our squad would have considered taking a class that took them away from their jobs, family and other commitments for more time than the present 110 hr requirement.

[hageremtp]

firefighterbeau brought up some great points on the BLS side of this. I also work and live in ND and see similar issues in the state if they change their standards. Its tough to get people to volunteer as it is right now. There are many reasons for this. One of the main things is time! I always use the example of what a new car cost in the 70's and 80's. There were lots of people wanting to volunteer. They had the time! Now think of what a new car costs, a home costs, etc. People are working more now, often times working more than one job, in order to pay for all the things in life they need or want. There just isnt as much free time anymore.

One of the biggest objections that I have is in the paramedic and advanced practice paramedic. At the paramedic level, as it stands now, they will take away Fibrinolytics from those of us that use them in the feild now. That will become an advanced paramedic thing. I also dont think that the required 4 year degree for the advanced paramedic is right! Why should an advanced paramedic have a 4 year degree when a RN can work with a 2 year degree? It just seems strange that someone would want to go to school for 4 years to be an advanced paramedic unless they are able to raise the wage as a perk (must be higher than it is now in order to justify). But thats just what I think.

[N2DFire]

Well there was a short but good discussion of the APP level itself in the ALS forum a while back.
(http://cms.firehouse.com/forums2/showthread.php?s=&threadid=64695)

I haven't read the entire document but I have read parts of it & I have read a lot of "theory & opinion" about it.

IMHO - I think that if this document becomes an actual national standard not just like the current DOT Minimum Standards or like NFPA which is a recommended standard then I can see both short term problems & issues but long term good for all field providers (and after all isn't long term where we should be focused?).

I think that a national standard of education & training would go a LONG way toward advancing our profession and could perhaps be just the catalyst we need to make that ever elusive jump from certification to licensure.

There is no type of change that is without transition issues however I think that we should look at these as the "growing pains" of our profession and not some type of mortal injury.

As I stated in my reply to the APP thread - we must all remember that these are still in the draft phase. They are still subject to (and most likely will) change - many times before a final revision is presented. I think that some of you raise great points of concern with this new standard but the question is - are you convinced enough in your concerns to make your voice heard?

The first round of public comment closed on January 30th this year. The document is now under revision based on comments heard thus far. Keep your eyes & ears open for the new revision & be sure to share your concerns with those involved with drafting these standards.

After all it takes very little additional effort to mail your comments in than it did to post them here.

I commend you all for not only making yourselves concerned but for making yourselves educated in the matter. Now I urge you to use any and all future opportunities to make yourself heard.


Comments and suggestions for improvements to this draft are invited. These may address the questions posed, structural aspects of the draft, clinical matters, or any other areas. If you have research, position papers, or other forms of support for your comments, please provide citations or copies. Please forward your comments in written form to:

Amy Starchville
National Association of State EMS Directors
201 Park Washington Court,
Falls Church, VA 22046-4527.

All comments received will be reviewed by the project’s Principal Investigator, Dan Manz, and the Expert Writer, Gregg Margolis. Depending upon the nature and subject of the comments, additional review by other members of the project administrative team, technical advisory group, or task force will also occur. It should be stressed that this draft is only a starting point for dialogue on EMS scopes of practice and that all input from any source is welcome and will be considered as the document is refined. Comments may be received through January 30, 2005.

[DrParasite]

I'd like to point out that in New Jersey, the DOH only recognizes EMT and Paramedic. They don't have a first reponder or an intermediate level. so this would totally screw up NJ even more than it already is.

[statler]

I like the idea of a national standard, as well as the opportunity for paramedics to enhance their skill set (and hopefully paycheck) with the APP.

I don't like the proposed restrictions on current paramedics. I work for a very progressive service right now, and the "prohibited skills" take away a lot of things that we are doing here, specifically: paralytics, thrombolytics, retrogrades, and blood products.

[pfd3501]

Standards have to make sense on a State and Local basis.

Speaking in generalities, what makes sense for an urban state may be a hindrance for a rural area.

[firenresq77]

I haven't read the draft yet, but how long is it going to take to get something similar for the Fire Service?