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New skills for rural and remote paramedics

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All paramedics want an expanded scope of practice. Those of us on the frontlines see the deficiencies as measured by the unmet needs of our patients and their families.

The needs of our communities and our medical system are not being met either as illustrated by continuing difficulties in recruitment and retention.

Change is coming

In Australia, the UK, the USA and Canada this change has been underway for quite some time now. Many communities have adopted an Expanded Scope of Practice model.

One excellent example is from Canada.

As far back as 1997, paramedics have been working in the Halifax Infirmary. At first, the assistance they provided was closely tied to their traditional role of transferring and resuscitating sick and injured people. But according to Dr. Sam Campbell, clinical chief of the QEII’s emergency department, opportunities to “expand their scope” were soon identified.

“They started doing things that their basic training put them in a good position to pick up as extra skills.”

Soon paramedics were assisting in the triage process, managing blood clots and helping to administer anaesthetic drugs, which demands very close monitoring for dangerous side effects. This alone led to decreased pressure on the operating rooms.

“It’s an extremely skilled job and the team has gotten better and better at it,” Dr. Campbell says.

Moving into the QEII’s Charles V. Keating Emergency and Trauma Centre in 2009 led to even more exciting breakthroughs.

“We had six extra beds so the suggestion was ‘Why can’t we roll this into a routine thing?’” Dr. Campbell relates.

The paramedics in this new “Pod Five” area continued to expand their role, taking on increasingly specialized tasks, such as casting and suturing.

“The paramedics are now teaching the med students how to suture,” Dr. Campbell says. “They’re the most appropriate teacher because they do it so often.”

“We now have departmental paramedics in the resuscitation and trauma area providing airway management, procedural sedation and analgesia. Another paramedic in the rapid assessment unit helps with surgery consultation. And primary care paramedics are helping with intravenous therapy, blood work and point-of-care testing.”

“Between 1,000 to 1,500 emergency procedural sedations are now done annually by paramedics,” Dr. Campbell notes. (1)

Another example is the BCEHS Infant Transport Team (ITT) which was established in 1976 to provide emergency medical care to pediatric, neonatal and high-risk obstetrics patients throughout British Columbia, the Yukon Territories, other parts of Canada and the United States. The ITT functions as a mobile Intensive Care Unit and is the only paramedic-based critical care team in the world that serves three distinct patient groups.

It is incredible to see paramedics utilized in this way, but throughout the world, this is the new norm as 3 compelling factors are driving the need for paramedics expanded scope of practise.

• Increasing demand in emergency departments

• Decreasing home visiting by medical practitioners

• Paramedics’ emerging professionalization

In Australia and the UK, paramedics have been given additional assessment, treatment and referral skills to deal with a range of minor injuries and falls cases.

In some areas, the ambulance service is contracted to supply an intensive care paramedic for rural hospitals’ emergency departments when a medical practitioner is unavailable. Paramedics work closely with nursing staff and they operate within their existing clinical practice guidelines and consult with the ambulance service medical officer as required. A significant feature of the program is that the paramedic role has changed from the traditional ‘scoop and run’ or ‘shifting the problem’ to one that requires more assessment, stabilisation and treatment

In other areas, paramedics with an Extended Scope of Practice (ESP) often undertake health promotion and illness prevention work, targeted to fit the needs of local communities:

In an article entitled ‘Extending the paramedic role in rural Australia’, the authors looked at several initiatives that have expanded the paramedic role.

This study demonstrated that paramedics can contribute to an improvement in healthcare service provision and that further expansion of their role may be possible. Many respondents to this study recognised that paramedics’ previous professional experience provides them with the knowledge, skills and experience to undertake broader roles than had previously been possible. They caution that to be effective and sustainable these roles must be supported by a robust education system that provides paramedics with broad knowledge, understanding, skills and professional attitudes that will enable them to operate as independent practitioner.

One of the medical practitioner respondents surveyed in this study, felt that the introduction of the new paramedic role had personally been a major retention factor because of the assistance it provided in after hours medical coverage. “Having [the ESP] here has been an enormous bonus to us, the practice. I mean before [the ESP] came I was on the verge of leaving the practice. (Medical respondent)” (2)

A very interesting paper by Bigham et all, undertook a systematic review of the international

literature to describe existing community paramedic programs. Among other things, they looked at some of the common skill sets for community paramedics throughout the world. Paramedics are now successfully demonstrating the following skills

• local anesthetic techniques

• suturing techniques

• joint examinations

• neurologic, cardiovascular, respiratory system examination

• ear, nose, and throat examination

• protocol-led dispensing including analgesia, antibiotics and tetanus toxoid

• mobility and social needs assessments

• requests for radiography

• referral to emergency department, general practitioner, district nurse, community social services (3)

On the east coast of Australia, In New South Wales, Extended Care Paramedics (ECP’s) perform the following advanced skill and procedures:

• Arterial gas sampling

• Urinalysis

• Peak flow respiratory assessment

• Wound care and suturing

• Local and regional anaesthesia

• Gastric tube insertion,

• catheterisation (both supra-pubic and indwelling)

• Splinting and plastering

• Dislocation assessment and management

• Multiple system assessments including home, Activities of Daily Living (ADL) – including mobility, falls and cognitive assessments.

• Administer several ECP only medications including analgesics, antibiotics, antihistamines, topical medications and vaccinations.

In addition to their initial training, these Extended Care Paramedics spent just nine weeks in a medical school environment that was focussed on attaining practical experience and integration with other health disciplines. (4)

As you can see, there are several examples of extended and expanded skills for paramedics and while the accomplishments of these paramedics are truly special, I feel that we are still overlooking opportunities to meet the needs of our patients as not all communities have employed a completely extended scope of practice in rural and remote locations.

At the other end of the spectrum, there are many Emergency Medical Responders (EMR’s) practicing in Canada and it may be time to expand their scope of practice. Currently, in British Columbia, EMR’s are still prohibited from treating life threatening asthma and anaphylaxis with ventolin and epinephrine respectively.

This seems odd in view of the 2015 International Consensus on First Aid Science with Treatment Recommendations Document which makes the following recommendation with regard to first aiders administering epinephrine:

“We suggest a second dose of epinephrine be administered by auto injector to individuals with severe anaphylaxis whose symptoms are not relieved by an initial dose (weak recommendation, very-low-quality evidence).”

It seems that the debate is no longer about whether first aiders – who receive significantly less training than EMR’s in BC – should give a dose of epinephrine but rather whether or not to give a second dose.

The ILCOR document goes on to say:

“While the included studies did not identify any adverse effects, selection bias might have prevented those effects from being identified. Adverse effects have previously been reported in the literature when epinephrine is administered in the incorrect dose or via inappropriate routes, such as the intravenous route. Use of auto injectors by first aid providers may minimize the opportunity for incorrect dosing of epinephrine.  While there are some risks, these can be mitigated by extra knowledge and training. Potential benefit far outweighs these risks.”(5)

Is it time to add an extended scope of practice for EMR’s? Presently, there is a large expense and time commitment to achieve Primary Care Paramedic (PCP) licensure and the time and the costs involved deter many excellent and dedicated practitioners. Could a shorter and more clinically focussed training program be developed to bridge the gap between PCP’s and EMR’s.

The paramedic role throughout the world is clearly shifting. These are exciting times for those of us on the front lines. Each year we learn and hone new skills to save lives, reduce suffering and provide comfort and healing. Our managers, regulatory bodies and educators are taxed to keep up with the advances in our profession. Other health care professionals are struggling to determine where we fit as we burst through previously established professional and clinical boundaries. Where will it lead? No one knows for sure. But one thing is clear. We have a unique and underutilized skill set and even more, change is coming. 

References

1. Expanding scope of practice, The QE11 Times, Paramedics an integral part of QEII’s emergency department, David Pretty. Internet. Available at http://www.qe2times.ca/expanding-scope-of-practice-232

2. Extending the paramedic role in rural Australia: a story of flexibility and innovation Rural and Remote Health 12: 1978. (Online) 2012. O’Meara PF, Tourle V, Stirling C, Walker J, Pedler D. Available at https://pdfs.semanticscholar.org/97cd/b593fafb4ba78a205986420ae4ad291c36a0.pdf

3. Expanding Paramedic Scope of Practice in the Community: A Systematic Review of the Literature.Bigham, Blair & Kennedy, Sioban & Drennan, Ian & Morrison, Laurie. (2013). Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 17. 361-372. 10.3109/10903127.2013.792890. Available at https://www.researchgate.net/publication/237055181_Expanding_Paramedic_Scope_of_Practice_in_the_Community_A_Systematic_Review_of_the_Literature

4. Redesigning paramedic models of care to meet rural and remote community needs Natalie Blacker , Lynette Pearson , Tony Walker. Internet. Available at https://www.ruralhealth.org.au/10thNRHC/10thnrhc.ruralhealth.org.au/papers/docs/Blacker_Natalie_D4.pdf

5. Part 9: First aid 2015 International Consensus on First Aid Science with Treatment Recommendations David A. Zideman et all. Resuscitation 95 (2015) e225–e261. Internet. Available at https://cprguidelines.eu/sites/573c777f5e61585a053d7ba5/content_entry573c77e35e61585a053d7bac/573c77e65e61585a053d7bb6/files/S0300-9572_15_00368-8_main.pdf

Dave Libby

Dave Libby

Dave Libby is a Commander and Advanced Care Paramedic with the County of Renfrew. He has been a paramedic in Ontario for nearly 25 years, working in a variety of settings, from remote Northern Ontario to downtown Ottawa. Back “home” now in Renfrew County currently with his wife and three sons, he is currently pursuing his Bachelor of Health Sciences from Thompson Rivers University.

Mike Billingham

Mike Billingham

Mike Billingham has enjoyed a challenging 36-year career as a primary care paramedic, critical care neonatal, pediatric and obstetric paramedic, station administrator and educator.

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