Tuesday, November 25, 2008


I just read the final version of the National EMS Scope of Practice Model, a document intended to provide a unified guideline for the scope of prehospital providers in the coming years. While I like the idea of cleaning up the fragmentary levels of training and scopes of practice across the nation, I cannot help but be frustrated when I read this document. It doesn't really change anything, it makes the system as confusing as ever, and it doesn't really work to bring the profession forward.

Therefore, I'd like to present my own scope of practice model -- okay, more of a manifesto -- for where EMS should be in 10 years.


Emergency Medical Technician - Essentially unchanged from the scope they retain today, the EMT should be able to provide life-saving care for critical patients until more advanced providers arrive, and transport patients who do not require advanced care.

Specific EMT skills: OPA/NPA, BVM, King Airway/Combitube, AED, oxygen, spinal immobilization, ASA for chest pain, SQ epi for anaphylaxis.

[ EMT-Rural - An optional intermediate life support module only for rural areas where there is no availability of paramedics. Adds basic 4-lead ECG monitoring, peripheral IV access, fluid administration, first-line code drugs (epi, atropine, amio, lido), and a few other basic medications (albuterol/atrovent nebs, NTG for chest pain, pain medication if transporting provider). ]

Paramedic - An improved version of the current paramedic standard, with a two-year schooling program and increased clinical/internship time. An Associate's degree and state licensure (NOT certification) are mandatory.

Specific Paramedic Skills: Endotracheal intubation, Rapid Sequence Intubation (with paralytics), surgical cricothyrotomy, nasogatric tubes, adult and pediatric IV and IO access, 12-lead ECG monitoring, interpretation, and transmission, cardioversion and pacing, IV fluid, expander, and blood administration, needle chest decompression, CPAP/BiPAP, and administration of a wide variety of medications with few, if any, mandatory OLMC consults.

Prehospital Physician Assistant - The PPA is an experienced paramedic who has gone to a fully-accredited PA school. They are deployed in small numbers throughout the system to address two populations of patients: first, the patients that require simple procedures or care which can be accomplished in the field and eliminate their need for transport; and secondly, the patients who require more advanced critical care interventions which are out of the paramedic scope of practice.

Specific PPA Skills - Critical care: Additional advanced airway options (retrograde intubation, LMA/ILMA, fiberoptic intubation), chest tubes, certain central lines (IJ/femoral), advanced medications (additional pressors, beta-blockers, mannitol, and others), Foley catheterization, pericardiocentesis, and more. Primary care: Wound cleaning and suturing, Foley/G-tube replacement, trach tube replacement, point-of-care lab testing, evaluation/referral option for non-emergent patients.

System Model

Prehospital emergency care in the urban area should consist of a tiered system of BLS, ALS, and advanced providers. A system should deploy a mix of EMT and paramedic ambulances, with a small number of single-PPA "fly cars" in the system.

Calls should be triaged according to an evidence-based model; for most calls both an EMT and paramedic ambulance should be dispatched. 4 providers onscene is an optimal number for managing both patients, and except in the simplest cases there will always be a paramedic evaluation of the patient. Patients will be transported by the appropriate ambulance, and if the patient is critical the EMT crew will assist the paramedic crew with transport (allowing both paramedics and one EMT to function smoothly in the back of the ambulance). On certain critical calls (cardiac arrests) a PPA unit will be dispatched as well, but in most cases they will be requested by providers onscene for either critical or simple patients. In the event of a critical patient the PPA will assume patient care and work with the paramedics during transport; on a simple patient the PPA will be able to free the ambulance and remain onscene to resolve the issue.

Fire department personnel will retain CPR/AED or First Responder certification, and will respond on traffic accidents, EMS requests for lift assists, and cardiac arrests, and other specific calls as needed. EMS systems will be encouraged to develop in-house tactical, extrication, and technical rescue teams.

Medical directors will provide primarily offline protocols with a high amount of ongoing education, case review, and training, particularly in high-risk/low-frequency skills. Wireless communications technology will be in place to allow providers fast access to physician consults if needed, with easy transmission of monitoring data.

That's my pipe dream...

Monday, November 24, 2008


Things change, as they always do. With my promotion to senior medic comes (along with other things) my own shift, my own car -- and a junior partner.

You never know who you will get, and it's the topic of discussion among the senior medics when the junior spot on your car is open.

"You'll get someone who's brand-new."

"They won't even know their way around."

"You'll have to babysit them, all night."

"I had a junior once, new guy, and you won't believe what he did..."

So with all this in my head, it was with no small trepidation that I waited to hear who my permanent partner would be. It could be someone experienced, I told myself. There are a few people who might want on my shift ... my night shift ...


And then the phone call, giving me the heads up and a name I didn't recogize. "Did she come from B shift?"

"Nope," said the voice on the other end of the phone. "She's brand new."


* * * *

So she came on the car. Young but sharp was my first impression, with a good attitude and a willingness to learn. But short on experience, she freely admitted, short on codes and tubes and all that fun. A white cloud, a medic who doesn't ever seem to get the critical calls.

Great. Just like me. We'll never have anything.

In the first week we had a truly critical call every single day.

And by the end of the week, I knew she was, indeed, solid; already a good medic despite her lack of experience, and with the potential to be a great medic.

* * * *

Of course, that's not all the responsibility I have to bear now. There's the narcotics, and making sure everything is in order, and doing little bits of paperwork for this and that.

And I guess there is one other thing.

* * * *

"Etomidate is in!" the fire medic announces, and swaps syringes. "Sux going in."

I look down at the patient. Sick, bad sick. Head injured. Unconscious. Jaw clenched. He needs an airway, needs PVC down his windpipe, and there's only one way to do that.

When you can't be trusted to breathe for yourself any more, we take over.

The drugs take hold, and he stops breathing.

"Okay," I say, softly, to myself, twisting my cap backwards and out of the way, clicking the laryngoscope open with a soft snick, taking a deep breath.

"Here we go."