With the United States population getting older and so many people uninsured, the workload for primary care physicians (PCPs), EMS systems and emergency departments is increasing. When patients can’t see their PCPs, they often utilize EMS to be transported to an emergency department, further stressing the overworked and – in many cases – understaffed emergency departments, coming full circle back to long wait times to see a hospital clinician. How can this be improved?
EMS in the United States continues to advance and adapt to ever-changing situations. One of those advancements is community-based paramedicine and adding advanced practice paramedics to the ranks. Much like a physician assistant or nurse practitioner, an advanced practice paramedic can be an extension of the physician with the capacity to perform urgent, life-saving procedures.
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Advanced practice paramedic scope of practice
The advanced practice paramedic will not be limited to the scope-of-practice currently in place. The APP will have the ability to provide critical, life-saving interventions that – in the past -waited until the patient arrived in the emergency department. Their scope of practice should include:
- Perform all procedures a paramedic may perform
- Initiate, manage and utilize an orogastric/nasogastric tube
- Initiate, manage and utilize a mechanical ventilator
- Initiate, manage and utilize airway management techniques:
- Endotracheal intubation via oral or nasal route, with the use of sedative and paralytic agents
- Video laryngoscopy and bronchoscopy
- Surgical cricothyrotomy
- Initiate, manage and utilize simple techniques for thoracostomy for tension pneumothorax, tension hemothorax or pneumohemothorax
- Initiate, manage and utilize chest tube thoracostomy
- Initiate, manage and utilize chest drains
- Initiate, manage or utilize all forms of vascular access
- Under ultrasound guidance, place central vascular access or deep vein cannulation
- Perform needle pericardiocentesis with ultrasound guidance
- Perform normal and high-risk childbirth
- Perform bimanual massage in life-threatening postpartum hemorrhage
- Perform ultrasound-guided nerve block
- Perform needle or surgical incisions and drainage of fluid filled oral or subcutaneous masses
- Initiate placement of and maintain urinary catheter
- Prepare, initiate and/or administer any medications or blood products under specific written protocols authorized by the medical director or direct orders from a licensed transferring physician
- Perform, initiate, perform and/or interpret a diagnostic test or utilize any diagnostic device under specific written authorized by the medical director or direct orders from a licensed transferring physician
- May carry out other tasks and procedures as authorized by the medical director or direct orders from a licensed transferring physician
Educational requirements
Dr. Elizabeth Powell, assistant professor of Emergency Medicine and Surgery at the University of Maryland School of Medicine, notes, “I see real benefit with properly trained paramedics providing these types of outreach services. Hospitals are full, staffing is limited and community outreach in the form of advanced practice paramedics could improve patient care and decrease readmissions to the hospital. The potential challenge I see is in the training involved.”
There are educational requirements to be considered. Advanced practice paramedics should come with an extensive background in a busy EMS or critical care system. The clinician is required to complete the Advanced Practice Paramedic course. They are required to have American Heart Association’s Basic and Advanced Cardiac Life Support, Pediatric Advanced Life Support and a specialty trauma certification, such as Prehospital Trauma Life Support. At the completion of the course, they will be evaluated and signed off on by the course’s medical director and the medical director they are working under.
According to the Global Emergency Medical Registry, the advanced practice paramedic is an individual who possesses the complex knowledge and advanced interventional skills necessary to provide physician extension to the patient’s side, allowing their physician medical program director the ability to have physician-level care extended to the scene of any emergency through the hand, eyes and ears of the APP. With medical direction oversight, the APP can perform interventions and patient care management with the advanced and diagnostic equipment typically find in an advanced response vehicle, an advanced practice ambulance or an emergency department.
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APPs and telehealth
APPs will have the ability to provide advice and recommendations to non-critical patients to ensure they receive the most appropriate care. The APP should be unrestricted as to the environment of practice or function and may serve as a physician extender for an authorized medical director in EMS, aeromedical, rescue, underserved populations or understaffed hospital emergency departments and critical care areas.
Powell pointed out advanced practice paramedics can also extend the reach of telehealth programs.
“For rural patients, getting to a hospital can be a really big deal and potentially put your EMS resource out of service for an extended period. In urban environments, hospitals are often congested and ED wait and holding times are long,” Powell said. “The benefits to patients with having advanced paramedic services will need to be balanced with the challenges that come along with work outside the hospital.”
Powell believes that having these clinicians in the field could help decrease ED overcrowding.
“EMS personnel know their communities better than we do in the hospital often. Patients are able to be met in their homes and receive a skilled evaluation. If there was also capacity to set up reliable short-term follow-up and transportation to outpatient settings, this could significantly cut down on hospital visits,” Powell said. “Incorporating technology and telemedicine services that already exist and are used in the hospital could certainly add to patient care and reduce ED crowding.”
