EMS Education — Some Easy Places To Start

Right now, EMS is being asked to step up its game and take on more of a role in healthcare.  Even before we knew about COVID-19, EMS was being asked to do more in terms of reducing repeat patients and finding alternatives to the “you call, we haul” mentality that’s been the mantra of the American EMS system.  Of course, that’s in large part due to much of EMS reimbursement being based upon Medicare and Medicaid reimbursement models, which often get adopted by private insurance as well. And since CMS pays for transport, not treatment, EMS is going to focus on taking patients to the hospital.  And in large part, the EMS education framework focuses on immediate life-threatening conditions and the treatment thereof both in the field and in the hospital emergency department.

However, we’ve reached a point where it might be valuable to reexamine our educational framework — and maybe even make a few changes that might improve our long term prospects for EMS.  Because of COVID-19, we’ve got two new challenges.  First, we’re being asked to do more in the prehospital arena.  In many locales, paramedics and some EMTs are now able to refer or transport patients to alternative destinations.  While this change was already starting to occur, COVID-19 accelerated this.  It’s now almost semi-routine for EMS providers to tell non-acute patients that a quick ride to the emergency department is no longer the solution, whether because of the load on the EMS system or emergency department saturation. In fact, the Center for Medicare/Medicaid Services (CMS) had already rolled out a pilot program for select EMS organizations to “treat and release”prior to COVID-19.  And during the current pandemic, CMS is authorizing payment for transport to alternative destinations and some “treat and release” scenarios. And second, because of the pandemic, many of the traditional EMS clinical rotations have become unavailable for EMS students.

Rather than seeing these challenges as threats, maybe it’s time for EMS educators to reevaluate how we’re educating our future EMS providers and what we’re teaching. Anecdotally, my EMS experience has been that a lot of EMS providers have occasions where they end up transporting patients to hospitals unable to provide definitive care for the patient.  Sometimes, that’s a result of protocols or local politics. However, many EMS providers often have a remarkable lack of knowledge about medical care and capabilities outside of emergency care. This leads to two pitfalls.  One, EMS providers take the wrong patients to the wrong hospitals. Two, EMS providers have little knowledge to fall back upon beside “transport to the emergency department.”

It’s time to make two simple changes to EMS education.  First, let’s add some education, even a few hours, on the rest of the healthcare system running the gamut from acute to sub-acute, from inpatient to outpatient, from primary care to specialty care.  And let’s talk about what the different healthcare professionals and medical specialties do.  Giving us a bigger picture of where and how we fit into the world of healthcare and medicine can’t harm us.  And for those that say the EMS curriculum is already full and “there’s no room to add any more,” let’s take a look at what we’re currently teaching.  I’m pretty sure we can sacrifice some dated or low frequency topics like the Kendrick Extrication Device, seated spinal immobilization, or petroleum gauze.  Next, while clinical sites are limited, let’s look at getting EMS students into alternative clinical settings.  I’ve long believed that a rotation in urgent care, especially a pediatric urgent care facility, might provide students as much, if not more, skills and observational opportunities than many current rotations — and might have a better connection to reality.  Also, I’d suggest that EMS students might benefit from time in physician’s offices, especially specialist physicians.  The opportunity to interact with physicians AND see how chronically ill patients are managed outside the hospital would give EMS providers much needed perspective. On the same note, I’d like to see EMS students given the opportunity to follow physicians on the hospital floors.  Seeing patients only in the EMS and emergency department setting doesn’t always give perspective to the continuity of patient care. And finally, seeing as how EMS often has to deal with the failures of our healthcare system, especially for elder care, EMS students need to be exposed both to skilled nursing facilities and also to hospital discharge planning.

Addressing the education if EMS while we’re currently dealing with COVID-19 and the current financial and educational climate will put EMS in a position to both improve patient care and expand the scope of EMS for the future.



A Solution to EMS Stagnation?

As I look at EMS’s stagnation in comparison to nursing, I have a thought. Nursing has made it where a Registered Nurse is the minimum level of entry to almost any acute care role — and where an associate’s degree is the minimum education level at best.

If we’re going to push the EMS degree narrative, we need to ensure that paramedics become the de facto provider of acute prehospital care. The Emergency Medical Technician should become the Certified Nurse’s Aide of prehospital medicine — in other words, not associated with acute care — except in a first responder role.  As a friend and colleague of mine noted, an EMT’s skill set makes an immediate difference in a few cases — rapid defibrillation, tourniquet application, and the use of an Epi-Pen.   Interestingly enough, those are all skills taught in the American Heart Association’s First Aid curriculum, once again providing credence to my belief that EMT education merely adds on to a general course in first aid.  While we’re at it, in my ideal world, EMT and paramedic education would be separate, albeit with a track to advance from EMT to paramedic.  You don’t have to progress from CNA to LVN to RN, although there are programs for LVNs to transition to RN.  We should do the exact same for paramedics.

Combine that with defining the role of a paramedic (which I see as rapid assessment, stabilization, and initial treatment) in statute and zealously protecting that role from intrusions by any other profession and you might actually get EMS to become more like nursing.  In my view, nursing has succeeded for three reasons.  First, nursing defines what it is.  Second, nursing makes sure that no one else intrudes on their defined role.  And finally, nursing is willing to engage in the political process to protect their role.

Let’s not do what Canada does and call every EMS provider a paramedic.  Let’s reserve the paramedic title for those who actually do what a paramedic does.  We don’t lump physician assistants and physicians together.  Let’s keep paramedic OUR title.  Of course, that also requires us, as paramedics, to educate the public and our government about what we do — which seems to be the one thing that we are still either unable or unwilling to.  See also:  the general public, other healthcare professionals, and government officials mixing the terms ambulance driver, EMT, paramedic, and first responder.

In summary, we need to define what a paramedic is, protect said role, and ask the public to demand paramedics.  As the advertising slogan goes, “Accept no substitutes.”

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EMS Continuing “Education”

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My Love Hate Relationship With EMS Social Media

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On Rhode Island

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Rural EMS and the Rural Hospital Crisis.

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The Matrix

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