Chapter 6 David C. Cone The Emergency Medical Services Systems Act of 1973 was the first formal national initiative supporting and endorsing EMS in the United States [1]. The Act defined 15 components of an EMS system, and this led to the development of the Department of Transportation’s national standard curricula (NSC), in an attempt to standardize the training of prehospital personnel: the first responder, the emergency medical technician-ambulance (EMT-A, which evolved into the EMT-Basic in 1994), the EMT-Intermediate (1985, revised in 1999), and the EMT-Paramedic (1989, updated in 1999). These curricula essentially evolved from the existing practices of EMS providers in the 50 states. It was not until 2005, almost ten years after the publication of the Emergency Medical Services Agenda for the Future in 1996 [2], that an educationally sound, scientifically based scope of practice process was implemented. The EMS Education Agenda for the Future: A Systems Approach was released in 2000 and called for the development of a system to support the education, certification, and licensure of entry-level EMS personnel that facilitates national consistency [3]. The Educational Agenda is a vision for the future of EMS education, and a proposal for an improved structured system. To educate the next generation of EMS professionals, The Educational Agenda builds on the broad concepts from the 1996 Agenda to create a vision for an educational system that will result in improved efficiency for the national EMS education process. The system will enhance consistency, education, [and] quality and ultimately lead to greater entry level graduate competence [3]. The Education Agenda proposed an EMS education system that consists of five integrated components: national EMS core content, National EMS Scope of Practice Model, national EMS education standards, national EMS certification, and national EMS education program accreditation. In 2004, the national EMS core content was released and defined the complete domain of out-of-hospital care [4]. In 2005, the National EMS Scope of Practice Model divided the core content into four “levels” of practice, defining the minimum corresponding skills and knowledge for each level of EMS provider, and established four levels: emergency medical responder (EMR), emergency medical technician (EMT), advanced emergency medical technician (AEMT), and the paramedic [5]. Each level represents a unique role, set of skills, and knowledge base for which the National EMS Education Standards define educational content [6]. The Education Standards define the minimal terminal objectives for entry-level EMS personnel to achieve within the parameters outlined in the National EMS Scope of Practice Model. Although educational programs must adhere to the Standards, its format allows for diverse implementation methods to meet local needs and evolving educational practices. The above five integrated components are intended to establish an educational system that, when fully implemented, provides the foundation to ensure the competency of out-of-hospital EMS personnel in a way that parallels other allied health care disciplines, as well as consistency from state to state. Note that the evolution and establishment of subspecialty recognition for EMS physicians intentionally and explicitly built on the same general structure [7]. A survey published in November 2011 noted that there were 826,111 credentialed out-of-hospital care personnel in the United States [8]. Until recently, there has not been a national system to aid states in the evolution of their EMS personnel scopes of practice and licensure. In 1996, there were at least 40 different levels of EMS personnel certification in the United States [2], with, for example, a number of different “EMT-Intermediate” definitions and scopes of practice used by various states, many of which did not match either the 1985 or the 1999 NSC. This diversity and patchwork of EMS personnel licensure and certification created several problems, including public confusion, reciprocity challenges, limited professional mobility, and decreased efficiency due to duplication of effort. The National EMS Scope of Practice Model supports a system of licensure that can be recognized across all states, establishes a platform for reciprocity, allows for professional mobility, and reduces public confusion. The authors of the National EMS Scope of Practice Model recognized the responsibility of the state regulatory process to help ensure the protection of the public. Part of a state’s regulatory responsibility includes the authority to establish the scope of practice for EMS personnel. Although this model is not intended to force standardization, it encourages national consistency of EMS licensure levels and their minimum competencies, while still accommodating some degree of state flexibility. “Scope of practice” is a legal description of the distinction between licensed health care personnel and the lay public, and also among different licensed health care professionals, creating either exclusive or overlapping domains of practice. It describes the authority, vested by a state, in licensed individuals practicing within that state. Scope of practice establishes which activities and procedures represent illegal activity if performed without licensure. Scope of practice does not define a standard of care, nor does it define what should be done in a given situation; it is not a practice guideline or protocol. It defines what is legally permitted to be done by some or all of the licensed individuals at that level, not what must be done (Table 6.1) [5]. Table 6.1 Scope of practice versus standard of care Typically, scope of practice refers to the tasks and roles that licensed personnel are legally authorized to perform. In general, it does not describe the requisite knowledge necessary to perform those tasks and roles competently. As outlined in the EMS Education Agenda for the Future, the major responsibility for determining the knowledge necessary to safely perform tasks and roles falls to educators. The authors of the National EMS Scope of Practice Model offer a schema to provide guidance on the presumed depth and breadth of cognitive material envisioned for each level of EMS licensure (Table 6.2). Table 6.2 Cognitive material envisioned for each level of EMS licensure AEMT, advanced emergency medical technician; EMR, emergency medical responder; EMT, emergency medical technician. The interfacility realm of EMS is an expanding domain in which EMS providers play an ever-increasing role. With interfacility transfers of critically ill patients going from primary to tertiary care facilities, there is a need in some EMS systems to establish the core foundation of education, medical oversight, demonstration of competence, and licensure authorization for paramedics to participate in this interfacility critical care practice. The current National EMS Scope of Practice Model provides the floor capabilities for all paramedics, but does not specifically address this specialized domain. In some cases, specialty certifications may be used to respond to local needs for flexibility or to recognize continuing education. Specialty certifications may evolve to accommodate subtle differences in skills, practice environments (e.g. tactical EMS, wilderness EMS), knowledge, qualifications, services provided, needs, risks, level of supervisory responsibility, and amount of autonomy, judgment, critical thinking, or decision making. Although it is beyond the purview of the National EMS Scope of Practice Model to define the wide array of possible specialty certificates that may exist now or in the future, some states are venturing into the realm of establishing one or more “specialty care” levels for the paramedic with additional training. A national model for this scope of practice has not been clearly defined, and currently the need is being addressed on a state-by-state basis (see Table 6.3 for a sample specialty care paramedic protocol, from Maryland [9]). Table 6.3 Sample specialty care paramedic protocol
EMS personnel
Introduction
Scope of practice
Standard of care
Purpose
Deals with the question “Are you/were you allowed to do it?”
Deals with the question “Did you do the right thing, and did you do it properly?”
Legal implications
Act of commission by an unlicensed individual is a criminal offense
Acts of commission or omission may lead to civil liability
Variability
May vary from level to level; does not vary based on circumstances
Situational; depends on many variables
Defined by
Established by statute, rules, regulations, precedent, and/or licensure board interpretations
Determined by scope of practice, literature, expert witnesses, and juries
EMR
EMT and AEMT
Paramedic
Critical
Simple
Fundamental
Complex
Emergency
Simple
Fundamental
Lower acuity
Simple
SPECIALTY CARE PARAMEDIC
(Paramedic only)
The Scope of Practice for the Specialty Care Paramedic (SCP) is defined by a floor and a ceiling of care. The entry level for this program is Maryland Licensed Paramedic. The floor of this Specialty Care Paramedic is the existing Maryland Medical Protocols for EMS Providers (MMPEMSP), including the Optional Supplemental protocols: CPAP, Glycopro- tein IIB/IIIA Antagonist, Heparin, Scene/Chronic Ventilator, and Mark I / DuoDote. (The Pilot programs and the Optional Supplemental protocols the ‘Wilderness’ and ‘Transport of Acute Ventilator Interfacility Patient’ are not included as part of ALS transports.) The medications and procedures listed within the Maryland Medical Protocols for EMS Provid- ers may be administered by the SCP based on the written interfacility transfer orders of the sending, Medical Director of the Commercial Specialty Care Service (without manipulation of the MMPEMSP), or receiving physician without having to request online base station medical consultation.
The ceiling for the Specialty Care Paramedic is defined by the medications and procedures that are defined as “Team” or are not listed within the tables below. Those medications or skills that are listed as “Team” require familiarization by the SCP but are the responsibility of the transport nurse or physician composing the patient care team.
If the medication or procedure are listed within the scope of practice for the Specialty Care Paramedic, this means that it is for both adult and pediatric patients.
The practice environment for these medications and procedures will be strictly for the interfacility transfer of patients and not extended into the realm of the 911 response.
Classification of Drugs and Procedures
S
Solo – Paramedic may initiate, monitor, and maintain without a transport nurse if they have successfully completed an EMS Board-approved Specialty Care program. (The Commercial ambulance must still meet the requirement of an additional ALS provider and EMT driver to complete the specialty care transport.)
T
Team – Means with a transport nurse or physician onboard – SCP needs familiarity with the medication or procedure but SCP may not perform or administer.
Medication – Procedure
A. Medications
Solo
(S)
Team with Nurse
(T)
1. Sedatives
a. Etomidate (amidate)
T
b. Lorazepam (ativan)
S
c. Midazolam (versed)
S
d. Propofol (diprivan)
T
2. Analgesics
a. Fentanyl (sublimaze)
S
b. Hydromorphone (dilaudid)
T
c. Meperidine (demerol)
T
d. Non- narcotic analgesics
(eg Ketorolac)
S
3. Paralytics
a. All types
T
4. Antihypertensives
a. All types
T
5. Volume Expanders
a. Albumin
S
b. Blood products
T
c. Dextran
S
d. Hespan
S
e. Plasmanate
S
6. Vasopressors
a. Dobutamine (dobutrex)
T
b. Epinephrine – drip
T
c. Norepinephrine (levaphed)
T
d. Phenylephrine
T
7. Bronchodilators
a. Metaproterenol (alupent)
S
b. Theophylline – IV
T
c. Terbutaline (brethine) – Inhaled
S
d. L- Albuterol (inhaled)
S
8. Anti-Anginals
a. Atenolol (tenormin)
T
b. Metoprolol (lopressor)
T
c. Nitroglycerin (tridil) – IV
S (adults only)
d. Propranolol (inderal)
T
9. Fibrinolytics/ Thrombolytics
a. All types
T
10. Anti-Coagulants /Anti-Platelets
a. All Types
S (adults only)
11. Anti-Emetic
a. All types anti-emetic
S
12. Antibiotics
a. All types of antibiotics
S
13. Miscellaneous
a. Flumazenil AD (romazicon)
T
b. Insulin – IV
T
c. Insulin in TPN
S
d. Mannitol (osmitrol)
T
e. Mg Sulfate (added to mixed drip– eg, with vitamins)
S
f. Potassium Chloride (only maintenance infusions; Not bolusing)
S
g. Sodium Bicarbonate Drip
S
h. Steroids – IV (not initiated)
S
i. Total Parenteral Nutrition (TPN)
S
j. Tocolytics (including Mag Sulfate)
T
k. Uterine stimulants (eg, oxytocin)
T
14. Anti-Arrhythmic
a. Amiodarone
T
b. Bretylium (bretylol)
T
c. Digoxin (lanoxin)
T
d. Diltiazem Drip
S
e. Esmolol (brevibloc)
T
f. Metoprolol (lopressor)
T
g. Procainamide (pronestyl)
T
h. Quinidine Sulfate & Gluconate
T
15. Anti-Convulsants (also see sedatives)
a. Barbiturates
T
b. Phenytoin (dilantin) / Fosphenytoin
S
c. Other non-benzodiazepine anti-convulsants
T
16. Diuretics (NEW ’13)
S
B. Invasive Procedures
(T)
1. Chest Escharotomies
T
2. Chest Tubes Insertion
T
3. Chest Tube or Surgical Drain with or
without vacuum system
S
4. Laryngeal Mask Airway (LMA)
S (adult only)
5. Needle Cricothyroidotomy
S
6. Rapid Sequence Intubation
T
7. Surgical Cricothyroidotomy
S
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Get Clinical Tree app for offline access