Since I wrote my EMS Bubble post I have received a lot of feedback.  This feedback falls anywhere on a spectrum between “I feel you brother” to “Are you nuts? Get that off the web!”  If you have a blog, it is easy to sit around and bitch about things you don’t like.  Coming up with a solution is hard.  Some of the negative feedback that I received simply assumed that I was making an argument that EMS was not necessary, and frankly that is just silly.  It is obvious that people need to be transported to the hospital by a competent medical professional.  However, many recent studies call into question exactly how we go about this.  The most immediate reaction to this is to go on the defensive and try to defend our profession against a perceived attack.  But is that really the right attitude?

I would like to ask the reader the following question: “Do you think EMS as it stands is perfect?  Or are there any changes you would like to make?”

Not long ago I heard a statistic that the average paramedic will only last in EMS for about five years before leaving the field.  (Where did I hear that?  Last year I was doing research on this topic for a class and for the life of me I cannot find the quote or citation…sorry.)  That is pretty poor, especially with the hoops one has to jump through to obtain the certification now.  I cannot imagine spending two years to train for a position I will only have for five.

There have been a lot of studies recently that suggest that EMS needs to go back to the drawing board with many of our practices.  Intubation is one of the controversial subjects right now.  I find it interesting that every time this comes up in conversation, the medic I am talking to will find fault with almost every one of these studies.  Either the sample was too small, or there was some flaw with the method of data collection.  However, where there is smoke there is fire.  The last ten or twelve studies I have looked at involving pre-hospital intubation have turned up results that paramedics don’t want to hear.  I thought about listing some of them here, but it would be tedious to do so.  Stop by the EMS Garage or some of the other blogs.  They have been arguing about this for months.  One thing I would like is for someone to point towards a recent study where EMS intubation was shown in a positive light.  Can anyone point to one of these studies?  I would love to read it and showcase it here.  But whether or not you like my conclusions about his subject, you can bet that you are going to hear it from somewhere else.  Too much evidence is piling up to ignore it.

But as I have said, pointing out the problem is easy.  The hard part is the solution.  Over the past several years I have been educating EMT’s and paramedics.  During this time I have gotten a lot of feedback from students, hospitals, EMS services, and other educators about the competencies of skills, and the usefulness of them when applied in the field.  So, I would like to try and describe what I think would work.

If I had the opportunity to change the certification structure in EMS (and this is an opportunity, not a setback) I would take the six or seven certification levels that are out there and reduce them to two.  The two certifications that are left will not resemble our current EMTs and paramedics either.  The primary certification should be something between the skills set of the current EMT and the paramedic.  This will be the primary certification for 911 response so for the purposes of keeping this straight in the reader’s mind I will refer to this from now on as Emergency Responder.  The second certification I will propose is much higher and will be discussed later.

Why aim between an EMT and a paramedic?  Well, as I have stated before, paramedics have a lot of skills that go unused in the emergency setting.  And the training of an EMT is many times considered not enough for all cases.  No offence is meant to EMT’s here.  This is why we have paramedics in the first place.  But the different skills sets and roles of EMTs and paramedics have confused hospital staff for years.  It has created two of everything: two certifications, two methods of education, two types of billing, and about 20 types of EMS services from all BLS, to all ALS, to tiered, and everything in between.  So simplification would be good for all concerned.  Wouldn’t life be easier if every time there was a 911 call in the United States, two Emergency Responders of the same level of training got into the truck and responded?

What does the skills set and training of this Emergency Responder look like?  Let’s talk about what I would add before I start talking about taking away.  First of all, I would add a lot of patient assessment to the initial training.  As a matter of fact, my idea of an Emergency Responder may get more training in patient assessment than paramedics get now.  This knowledge would then be applied to get the patient to the right specialist in a timely fashion.  I have met many EMT’s who can do some pretty spectacular patient assessments by drawing upon their experience.  But I have known very few recent EMT graduates who can talk about local stroke teams, MI criteria, NICU’s, and other specialties with confidence.  The very reason we exist is to transport patients to definitive care.  But for some reason many EMS services have always considered themselves to be separate from the hospitals.  To do what is in the best interest of the patient, we have to jettison this attitude and think of ourselves as an extension of hospital triage.  Accurately assessing a patient’s illness and injury, and transporting that patient swiftly to the correct specialty with the best chance for a favorable outcome should be our absolute number one priority.  Sadly, many services do not even have a mechanism by which to track whether or not a patient was transported to the best facility or not.

I would also add a lot of training for infection control.  I have always thought that infection control was lacking in the basic EMT class, and I have often times been alarmed at how little some of my EMT partners have known about MRSA, VRE, and other types of infections which require various isolation techniques.  To be quite honest, the average nurse’s understanding of infection control is inadequate.  Trying to practice infection control in a moving vehicle presents challenges that complicate this already difficult subject, and initial training needs to reflect this.

So what would I take away?  You know I am going to say it, so let’s get it out of the way.  Yes, I would take intubation away.  The recent bad research is coming down on us like a hail storm.  But that isn’t the only problem.  Education and initial competency have proved almost impossible in recent years.  When I was a regular on the EMSEduCast I talked to many paramedic educators who had sad tales of not being able to reliably get students live intubations during their hospital clinicals.  It seems that more and more anesthesia groups do not want students to add further liability to their situation.  The recent popularity of the LMA has also decreased the amount of intubations available to a student.  Many of my students came back from surgery rotations complaining that out of almost a dozen surgeries that were occurring that day, not one of them was an intubation.  I also have a bit of a dirty secret.  When I graduated paramedic school in 1996, I had never once intubated a live subject.  I had gone to surgery clinicals, but was never allowed to do anything but watch.  The first time I ever did the procedure for real was when I was cleared and practicing in the field.  From talking to other providers I have found that my experience is not uncommon.  The current literature suggests that it takes 50 repetitions to become competent.  How about zero?  Is that appropriate?  There are also many services where the medic to intubation ratio is horribly skewed.  A few months ago a colleague told me of a fire based metropolitan EMS system that contained almost 1200 paramedics.  This system only had about 350 intubation opportunities per year.  You do the math on this.  Can anyone remain competent in a skill if they only practice it once every three years?  Recent technological advances have provided us with several alternatives to intubation.  It is high time that we started to re-evaluate this.

I would also seriously consider taking the monitor off the truck, and replacing it with an AED.  I have told my students time and time again to ignore the monitor when they suspect an MI.  I have told them that 20% of MIs show no changes on a monitor.  I have seen people in the back of my truck go straight into v-fib from a beautiful looking sinus rhythm.  I have also seen my 12-leads crumpled up and tossed into an ER trash can.  So I am starting to take the hint.  I don’t need a 12-lead to know when a patient needs aspirin and nitro, and many EMTs across the nation giving these drugs without ever seeing a monitor strip.  The time and money saved by removing monitors from the truck would be immense.

Would Emergency Responders start IVs?  Yes.  Fluid resuscitation is still useful and very easy to train.  The benefits outweigh the risks, and outcomes are affected.  However, the drug list for the Emergency Responder will not be as large as the paramedic, so IVs really will be for fluid resuscitation and dextrose administration only.

Now that I have mentioned the drug list we may as well explore that.  Most of the drugs in the Emergency Responder arsenal will consist of drugs available to current EMTs.  Aspirin, nitro, epi 1:1, oral glucose and the other usual suspects will be present.  However, I would like to add glucagon, dextrose and benadryl.  I have often thought that EMTs do not give enough drugs, and many paramedics only pull certain drugs out of their kits when they expire.  The one unknown here is pain control.  Pain control in the pre-hospital setting has been shown to be beneficial.  But it has also been heavily abused.  Is it worth the trouble?  To be honest, I simply don’t know.  I attempted to read up on this a bit before I made this post, but to be honest I think I am more undecided now than I was before.  I simply don’t know the answer to this one and I hope that more studies are done soon.

So, in the end the Emergency Responder would look a lot like an EMT as far as skill set.  What would be added would be IVs, and a little bit of expanded pharmacology.  What would be greatly expanded is patient assessment and knowledge of the hospital system.  This certification would be the entry level for EMS services, and the backbone of 911 and non-emergent transport.

But I did mention another certification didn’t I?  Actually, certification may be the wrong term for it.  I would like this provider to be a licensed and have a bachelor’s degree.  This licensure would look a lot like a critical care/community paramedic.  The education of this provider would allow him or her to make interfacility transfers with ventilators, ECGs, multiple drips, and chest tubes.  Sedation, and pain control would be possible.  And the ability to function independently as a ‘community paramedic’ would be part of the initial education as well.

In all my years in the field, I have often observed that transport medics longed for 911 jobs, thinking they would be a new challenge, only to be let down by the realities of that job.  In contrast, I have seen medics used to working for 911 systems attempt to get a part time job at a transport agency and become overwhelmed by that patient with five drips, two chest tubes, and a ventilator.  I have worked in both theaters, and enjoy either side when done correctly.  However, it has always confused me as to why more respect is perceived for one position over another.  Often the perception of difficulty, skill, or knowledge is quite wrong.  Believe me, I am fully aware that working for a transport agency can be less than glamorous.  But glamour is not a measure of difficulty.

The critical care/community paramedic would feel at home during serious ALS transports, critical care and flight operations, and the expanding field of community medicine.  And if a student is going to pursue something such as this I think that RN licensure is not too much to ask.  Now, before the hate mail begins to flood in, I am not suggesting that nurses be put on a truck.  I am suggesting that a four-year degreed medic should have more career opportunities available.  The college based medic programs in other countries lead to RN licensure, and I don’t think that is too much to ask, especially if these medics will be taking over the care of ICU patients.

Anyway, I hope this explains my position a little more.  I have gotten a lot of mail in my inbox recently that has accused me of being burned out or hating EMS in general.  I assure you, nothing could be further from the truth.  Well…okay, maybe I’m a little burned out.  But its nothing more than usual.  Those people who thought I had completely given up on EMS may be surprised to hear that I think the minimum certification for someone in the field would be something beyond the scope of EMT.  They may also be surprised that I am calling for another certification higher than that needing a degree.  So this post is for you.

However, I think the controversy (and much of the misunderstanding) comes from my belief that the average 911 system could be well handled by someone with a bit less training than the current paramedic.  But so many services across the country have resorted to allowing BLS crews to take to the streets and transport without medics if one is not available.  Many rural systems have gone without medics for years and get by just fine.  I personally work for a system that went ALS in 2007.  The EMTs that work for this system are of a very high caliber.  I often find myself just standing back on scene and watching them work.  I seem to step in for a very narrow band of situations which I have tried to reflect in my description of the new Emergency Responder certification.  What I would really like to see happen in my district is a community medic program.  And although I think there is a real need for it where I work, I also think that we are several years away from considering it.

So to all those people who thought that I hated EMS, you were a little off in your assessment.  But now that I go back and read some of the stuff that I have written over the last few weeks, I know where some of that perception came from.  I was having a conversation with a colleague a few days ago about these posts, and where I thought EMS should go.  He told me, “No one can tell that from what you have written so far!”  And I am not sure why you all can’t read my mind, but I am disappointed in each and every one of you.  So here you go.  Maybe after this you will find a whole new set of reasons to be angry with me.  I don’t know.  But I’m sure I will find out.

As for the validity of my ideas, I don’t have much to tell you.  No one is going to read this blog and gut the EMS system as we know it.  Forget a blog post, this subject could fill a set of books.  Obviously, more studies will have to be done, and people smarter than me will be deciding what happens.  However, I will make this prediction: no matter what you think about intubation, it is about to be questioned by a bunch of physicians.  If you don’t agree with my assessment of the situation, that’s fine.  But those of you who wish to keep this skill in your bag of tricks better start preparing your arguments now.  Your medical director may be reading recent studies right now and reconsidering her opinion.  It happened to the London Ambulance Service and it could very well happen to you.

Fell free to add your own opinion in the comments section.  I enjoy discussion on this topic.  All seething anger can be directed towards hatemail@gomerville.com.

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