I am proud to be a paramedic. I believe paramedics save lives. If I or one of my family members were critically ill, I would want a seasoned paramedic taking care of me rather than a brand new basic EMT. When I say paramedic, i mean that in the sense of a health care provider with the intelligence and common sense to do what is right for me and my family, and not just someone with the words PARAMEDIC on their shoulder patch –someone who knows when to use basic skills and when to advanced skills, not someone who uses advanced skills because they can.
There is a division between EMT and paramedic that many view like this: Paramedics give medicine and provide advanced skills, EMTs do not. (I prefer the division to be paramedics have more advanced assessment skills). When I started as an EMT, the only medicine I could give was oxygen. We had no advanced skills. We didn’t even carry automatic defibrillators.
Slowly over time, EMTs have been given more to do/responsibility. Here in Connecticut, EMTs can give aspirin, use EPI pens (and now use check and inject to draw epi up in a syringe), administer naloxone intranasally, defibrillate, capture, but not interpret 12-lead ECGs, use glucometers, and administer CPAP. Some of these like ASA, glucometers and CPAP require approval of their sponsor hospital. I helped write the education for BLS Naloxone and was behind the proposal for BLS CPAP.
I believe EMTs should be able to do whatever will benefit their patients with limited risk of harming them. I am even for EMRs (emergency medical responders) doing more if they meet this criteria.
Recently I sponsored a proposal to permit EMRs to administer naloxone by syringe. With the expense and occasional shortages of intranasal naloxone I felt that this would be a good idea. EMRs are already trained in giving IM naloxone by autoinjector. How difficult is it to draw 0.4 mg/cc from a one cc vial? (In Connecticut lay people are allowed to do this and five minutes after training they can stick the syringe in the leg of a stranger overdosed on a bench outside of Walmart.) Most of the EMRs in our state are firefighters or policemen. It’s not like they aren’t already trained and trusted to do far more complicated procedures in their fields. While I am pleased the measure passed (and is currently awaiting signature of the commissioner) there was a degree of opposition, and one of the arguments was skill creep. Skill creep means EMRs and EMTs slowly doing more and more of the things paramedics do. Someone said, “What will they be doing next, giving IM epi?”
Wouldn’t you know it, at our next meeting there was a proposal for EMRs to carry epi-pens. This is currently prohibited in Connecticut, but allowed in several other states. The proposal came from family and friends of a man who died of anaphylaxis. He did not know he was allergic to bees. He was stung, and died before the paramedics could arrive 11 minutes later. When first responders arrived 5 minutes after the 911 call he was still conscious and breathing. We passed the proposal in our region under the proviso it would only be allowed with sponsor hospital approval (a condition similar to the IM naloxone). It is hard for a medical director to vote against a proposal that would prohibit a fellow medical director from training and approving his services from doing a skill or procedure that is permitted in other states.
Many years ago, I did an exercise where I had to rate every medication I carried and each day I had to remove one medication until I only had one left. The one I chose if I could only carry one was epinephrine 1:1000 for anaphylaxis. My second through fifth choices were Morphine (we didn’t carry fentanyl then), oxygen, ativan (we didn’t carry midazolam) and duoneb. I had naloxone ninth because we can always breathe for someone with a bag-valve-mask if we are out of naloxone.
There are few calls where an otherwise healthy and often young person with a full life ahead of them can die so quickly if they don’t receive an intervention within minutes of an anaphylactic insult. If you don’t have epi when someone’s throat is closing up and their pressure is dropping, you are out of luck. And they are too. I have had a few severe anaphylactic calls where I thought the patient was going to die, but the epi saved them. If anyone in my family or any close friend or any stranger for that matter is in anaphylactic shock, I want the first EMS person, paramedic, EMT or EMR coming through the door to have epi on them. I would rather have EMR with epi now than a paramedic five minutes later when it is too late.
I read an interesting article in JEMS this week, written by long-time EMS guru Bryan Bledsoe. In it, he says “it was never intended for the primary EMS provider to be a paramedic…It was always intended that the principal level of EMS provider would be the emergency medical technician (EMT).” EMTs were supposed to carry the load. I have come to feel the same. I believe EMTs are capable. Arm them with whatever they can use to help save a patient’s life until a medic arrives if needed (for a call requiring advanced assessment and more comprehensive medications and/or skills that EMTs don’t do). There is a proposal coming soon to our region for EMTs to insert I-gels in cardiac arrest. I support this, too. I-gels are simple to insert and work. Allowing EMTs to insert them before a medic arrives will improve cardiac arrest care.
When I started there were very few paramedics. Most of our calls were for serious emergencies or to intercept with basics. As Bledsoe points out in his article, changes in reimbursement, which provided more payment for ALS assessment, spurred services to add more paramedics to the road. Now where I work there are so many paramedics that most spend half their days doing BLS transfers, while EMTs rarely do 911s. The medics don’t have the experience they used to and neither do the EMTs. Not the ideal situation.
Let’s always approach each situation from the perspective of risk/benefit and evidence — not from the perspective of that’s how we’ve always done it.