California Paramedic Regulations are Open for Public Comment

Posted by Patrick Lickiss on Sep 21, 2011 in Current Events, EMS 2.0, General, Treatment | 26 comments

Did you hear that? That was the sound of my brain exploding. Seriously. If you’ve read this blog for any length of time, you’ll know that I’m a huge advocate for expanding the role, educational requirements and scope of practice of prehospital practitioners. I may finally get my vindication.

The State of California is looking at revising their scope of practice to fall in line with the National Scope of Practice Model. This can’t happen soon enough. There are three main areas of focus: additions to the paramedic scope, establishing a standard for Critical Care Transport Paramedics (CCT-P) and Advanced Prehospital Paramedics (APP) and revising minimum standards for controlled substances management. Since narcotic control is a dissertation in itself, I’ll focus on the first two topics today.

BASIC PARAMEDIC SCOPE
Alameda County readers of this blog will note that many of the changes detailed below represent medications we already give and treatments we already perform. It’s important to note that local medical directors ultimately control what happens in their system and that many counties have requested permission from the state to incorporate these treatments already. Adding these to the state scope means that special permission won’t be necessary and that local medical directors can add these items to their protocols with ease.

Medications

Amiodarone
Dextrose 10%
Diltiazem
Fentanyl
Ipratropium
Lorazepam
Magnesium Sulfate
Ondansetron (Zofran)
Potassium up to 40 meq

Procedures

External pacing
Perilaryngeal airways and pediatric endotracheal intubation
CPAP/BiPAP
Intraosseous Insertion
Prehospital lab tests including capnography and carbon monoxide monitoring
Naso and orogastric insertion and suctioning
Intranasal medication administration

Not a bad list of additions if you ask me. I’m glad to see a move towards fentanyl for pain management and I think that lorazepam is better suited for sedation than the midazolam most of us are using now. Standardizing CPAP and IO usage is a great idea as well. We’ve had excellent results here with both and I think those skills will serve other systems as well.

CCT-P/APP
Now this is what I’m really excited about. Several counties in the Bay Area have implemented CCT-P programs but this opens that idea up to the rest of the state and expands to allow advanced ALS practitioners. The state would standardize the training programs for both designations and allow local medical directors to authorize these levels of care without additional state approval. Let’s start with the CCT-P scope:

Set up, maintain and troubleshoot thoracic drainage system.
Set up, maintenance and troubleshooting of a mechanical ventilator.
Set up, maintenance and troubleshooting of fluid delivery pumps and devices.
Administer medication infusions during interfacility transports including, Heparin, blood and blood products, Glycoprotein IIB/IIIA inhibitors, nitroglycerine, norepinephrine, TPN, and thrombolytics.

Not too shabby. This allows systems to develop CCT-P level interfacility units with the ability to backup the 911 system, or to train a portion of their 911 responders to perform these transfers, depending on the volume of either type of call. I’m actually an advocate for the second option. By providing advanced training to interested 911 responders, you not only obtain the ability to utilize them for complex transfers (which likely have a higher reimbursement success rate than 911 calls) but you also win on the 911 side by having better trained providers caring for your emergent patients. Everyone wins.

Now, on to the coup de gras…Advanced Prehospital Paramedics:

Perform digital and nasotracheal intubation procedure.
Surgical cricothyrotomy.
Perform procedure for facilitated intubation using sedation and neuromuscular blockade.
Set up, maintenance and troubleshooting of a mechanical ventilator.
Administer medication including succinylcholine and etomidate.
Administer OTC medications.
Assess and refer patients, and assess and provide treatment without transport.

Now the likelihood is that I’ll be writing about this level of care for some time to come so let’s start with the big one: ”Assess and refer patients, and assess and provide treatment without transport.” Simply awesome.

One of the biggest roadblocks to APP programs is the inability to bill for services. State and Federal insurance programs (and most privates) reimburse for transport only. The addition of treat and release/treat and refer to the state scope is a huge step towards advocating for EMS reimbursement for those programs. Making those programs sustainable means that they can be rolled out on a state-wide basis. Now you see why I’m so excited about this and I hope you are too!

If you’re interested in reading the regulations in their entirety or making your voice hear during the public comment period, head over to the EMSA website. The period for public comment ends October 24th!

What are you looking forward to in the future of EMS? Were any of those addressed in this scope update? What are your next steps towards making your EMS dreams a reality?

Image via Flickr

James Marshall Clary

Minimum education for an app then should bs masters level.

http://510medic.com 510medic

Though I’m inclined to agree, the lack of any clinical Bachelors or Masters degree in EMS would make that seem like putting the cart before the horse. Not saying that these degrees shouldn’t exist, just that they don’t.

I’d support extremely stringent educational requirements for APPs but wouldn’t necessarily link it to a degree program to begin with.

Christian

If those degrees exist I believe we would start to lose pre-medical students to them. The issue then becomes whether we want an experienced EMT to be going to medical school without a stringent knowledge of the sciences or whether the sciences come first. I’m on the pre-medical track myself and I know I’ll have vast experience in patient care that many other MD’s won’t. I also however don’t have a thorough background in science because I did not get a BS in Biology, mine is in psychology (lending itself more towards patient comfort and advocacy).

Do I think I’m extremely smart? Not particularly, but I do have experience most medical students don’t have and a keen understanding beyond the books of what it means to be in an emergency setting making split second decisions.

http://emtmedicalstudent.wordpress.com/ Joe Paczkowski

A “stringent knowledge of the sciences” isn’t really required for medical school. A year of bio, year of chem, year of o-chem is the standard, with a good portion of schools requiring a year of math (calculus or calculus and statistics) and/or a year of physics. None of the courses have to be upper-division level courses, and it’s not an oversight that courses like A/P aren’t required.

These requirements aren’t going to change just because a student has a degree in EMS. Similarly, medical schools aren’t going to just stop teaching anatomy, physiology, pharmacology, pathology, etc just because some of their applicants has an EMS degree. More importantly, how many providers is EMS losing to medicine and nursing because of the lack of freedom and ability to advance in the average EMS system? Personally, I’d rather risk losing a few providers with an EMS degree to medicine than the likely larger number who currently never enter, or quickly leave, EMS because of the current environment and culture.

Dustin Galliazzo

This is absolutely untrue. An expanded scope of practice equates to being good at writing term papers and regurgitating information? Degrees from these increasingly political institutions of ” higher education” do NOT instill common sense. They do NOT substitute for boots on the ground experience and that 6th sense that your patients about to head south. Requiring degrees will only bring more ego fueled medicine (along with theyre lethal mistakes) and prevent good experienced paramedics who have the common sense and “street smarts” that have and will save more lives than a degree EVER will.

http://emtmedicalstudent.wordpress.com/ Joe Paczkowski

What good is street smarts and experience with out a scientific and clinical basis to work off of. Telling someone that they don’t need to go to the hospital is inherently different situation than deciding which hospital the patient needs to go to and only being responsible for the next 15-20 minutes of care.

Power without knowledge is dangerous.

Toddwright

I think we should have degrees for the jobs we do. If you take the amount of college hours from EMT-B, EMT-I, and EMT-P along with all of the required classes, ride times, er times and other clinical hours we as a Paramedic go through more than enough hours to at least earn a 2 year degree. This would allow or maybe pave the road for paramedic pay to increase. Here where I work a Paramedic earns about 35k and most work 2nd or 3rd jobs to make ends meet. If I wanted to be a nurse I would have gone to nursing school…I enjoy working in the streets, I honestly enjoy going into a persons home and being the first medically trained person to take care of them until we reach the ER. I dont want to be in an office or hospital setting, if thats for you fine go for it…if being a flight medic is for you go for it. But lets work on teaching better care for our customers and with better teaching/learning should come better pay.

Most medics get into this job not for the money but to make a difference in someones life. I know I did. I strive to learn the newest, latest and greatest information out there. I’m always on the internet searching and researching of better ways to do the job, better ways to provide the best care I can.

http://emtmedicalstudent.wordpress.com/ Joe Paczkowski

I agree that EMS, starting at least at the paramedic level if not earlier (personal aside, I’d like to scrap the entire system and start anew because I think there are serious structural and cultural issues, but that’s not happening any time soon, if at all), but a college education shouldn’t be about the number of hours. Ideally it should be about the level of information AND how that information is used. There’s a fundamental difference between the thought process of “give drug X because the protocol says so” and “give drug X because it’s the right treatment because…”

For EMS to get better reimbursement and respect from the health care community outside of emergency medicine, EMS needs to prove that they’re professions instead of technicians (standard disclaimer: Where EMS should be, and where they currently are as a whole is two different things) and prove that they’re worth more than a quick trip to the hospital. Community paramedicine and degrees are two great steps towards that. The only real question is the general apathy of EMS providers enough to stop progress?

http://510medic.com Patrick Lickiss

Well said!

http://510medic.com Patrick Lickiss

I actually have to disagree. While a degree does not bring with it a gut instinct about how to care for patients, it does ensure that a paramedic has a standard base of knowledge. Learning subjects like anatomy and physiology and pathophys from subject matter experts (not necessarily former paramedics) can set a practitioner apart from a clinical standpoint.

Both experience and education are vital. Assuming that formal education won’t benefit patients is as foolish a statement as saying that hands on experience won’t benefit patients. An APP would require both.

Bdiregolo

Nice article….hopefully California will step up and make this happen sooner rather than later!
http://burnedoutmedic.com Burnedoutmedic

hoping for a push towards patient education, something the medical establishment is terrible at.

http://emtmedicalstudent.wordpress.com/ Joe Paczkowski

Is the medical establishment terrible at patient education, patients terrible at following through with said education, or a combination of both. [insert horse to water cliche here]
http://510medic.com Patrick Lickiss

I think that is the only way this could ever work. It would require management and clinical support for those types of decisions on scene as well.

Chipphelan

All of those listed are standard practice for paramedics in many states including here in Missouri. I did not know California had so many limitations.

http://510medic.com Patrick Lickiss

I’ve heard it said that California has more attorneys than people. That may have something to do with it. No offense to any attorneys reading this…

One10Star

Nothing beats hands on in a real world setting. Give me a war harden Corpsman and see how he/she stacks up to a “Masters” educated individual. Oh wait, I had the honor of working with men and women who had BOTH! They will tell you, nothing like getting your hands dirty to learn the real deal the books can’t begin to offer!

http://510medic.com Patrick Lickiss

Both would be required in my perfect world. One still needs the background education to be able to practice good medicine.

http://twitter.com/lpndj6 David Jewel

As a former EMS provider Im always for advancing medical care. Because
something doesnt exist doesnt mean it shouldnt. The push to for higher
standards is coming across the board. by 2020 they want to have all
Nurse Practioners trained to the Doctorate level and this isnt a theory
type degree program. The new programs are a DNP Doctorate of Nursing
Practice which focuses on exactly that practice. a Masters in EMS
practice would certainly be a positive step I believe. I know there has
been always this issue many have either from a nursing perspective
against EMS or vis versa and I can say having been on both sides of the
fence there is no reason why both schools of thought have ot be mutual
exclusive. EMS primary focus has been on keeping patients alive while
nursing has focused on getting people better. A better understanding of
why paramedics do what they do and why as well as assessing the whole
picture would benefit patient outcomes overall. EMS has come a long way
from the early days of orginally scooping and scooting down the road
with barely first aide as far as training to move invasive procedures
such as IVs and defibrillators to doing amazing things such as 12 lead
EKG in the field to cut down on time of onset of symptoms to the cath
lab for STEMI and even in some cases use of blood products in field for
trauma patients. Skills are great but I agree the reasoning behind them
should be understood as well. Advanced education in clinical thought
process is always welcome and should be what every provider be they
pre-hospital or work acute/sub acute in fixed facilities.
Anonomus

out of that list, this is what i pulled off of it that are EMT-I stuff in two of three ststes i worked

Dextrose 10%
ipatropium
pediatric endotracheal intubation
CPAP
Intraosseous Insertion
Prehospital lab tests including capnography
Naso and orogastric insertion and suctioning
Intranasal medication administration
Anonomus

out of that list, this is what i pulled off of it that are EMT-I stuff in two of three ststes i worked

Dextrose 10%
ipatropium
pediatric endotracheal intubation
CPAP
Intraosseous Insertion
Prehospital lab tests including capnography
Naso and orogastric insertion and suctioning
Intranasal medication administration
FLreSident

All of the drugs and procedures mentioned are already in place in Florida and have been for some time now. I always thought California was the leader in advancements for Paramedics but I guess I was sadly mistaken. I hope CA can catch up and make a big impact in patient care.

http://emtmedicalstudent.wordpress.com/ Joe Paczkowski

Are you kidding? EMS is a leader in EMS, we’re just stuck in the era of Johnny and Roy!
Kingsmedic1

Many of these skills are performed in california on regional basis. The state legislature is just catching up with the laws on the books.

Ohpuddleduck

Curious about where you got this information from – these “proposed amendments” to the paramedic regulations they are not even in public comment yet.

Thank you for jumping the gun.
BH

EMS talks a good game about becoming a profession, but won’t put in the time, effort, and sacrifice necessary to attain it.

RNs knew that education is the answer. RTs knew that education is the answer. Both are now full-fledged members of the medical profession.