Nov 25, 2014
Last week, Justin Schorr, The Happy Medic, stepped up on his virtual soapbox to let the EMS world know what he thought about Community Paramedicine. I was to surprised to find that Justin, a rather vocal advocate of reducing needless EMS volume, was against the measure saying that it was “too important to be trusted to the 911 crowd” saying that it needs to be a specialty and not a “spin off” of our current EMS system.
From one end, I can see where Justin is coming from. As a paramedic in a busy urban 911 system, demand and the current work load for paramedics is high. When you are stretched thin, and your workforce is not deployed to reflect the needs of the community, then every warm body that you have becomes important and no matter what we do, response to emergency calls will always be the primary mission of a system like Justin’s. To add to that Justin works in a fire-based system. Far too often in fire-based EMS, running the ambulance is seen as a subspecialty thereby turning Community Paramedicine into a subspecialty of a subspecialty. With the additional training that should come along with the title Community Paramedic, a person is effectively being asked to wear “three hats” instead of the two that they were hired to wear. That might not exactly be true in Justin’s system but plenty of providers can attest to this.
In all reality, what else do we have in our potential toolbox that will help us reduce those unnecessary EMS runs? As it stands now, Community Paramedicine is the best option. Justin is quick to point out that when he was in England, “paramedics with only 1 year experience were out on their own making recommendations, referrals, and taking people directly to what they needed, not just a 2 person cot van to an ER.” The difference there is training and education. They were prepared for such an event and although there have been limited studies done on the matter, the evidence exists that paramedics in the United States do not do a good job determining who should and should not go to an emergency room.
Justin with Medic999 himself Mark Glencorse
This would be the perfect point in this post to slam the effectiveness of home nursing, and while I personally am not a fan of much of the care that I have encountered from it, I think it is more important to stick to the positives of Community Paramedicine rather than the negatives of the existing safety nets that exist for patients. When done properly, Community Paramedicine works and it works well. MedSTAR has shown us, Eagle County, Colorado has shown us, Wake County has shown us, and even AMR out in Alameda County had a great deal of success with it. Those systems all have a few things in common. For one, they are all single role EMS systems. They also each have very high standards for the care that they provide, and high standards for those that they deem worthy of participating in their systems as Community Paramedics. The standards guide them, and the lack of standards is what is holding us back.
The real issue is we have allowed the water that Community Paramedicine is being born in to become muddied. In a comment on Justin’s post, Skip Kirkwood restated his position that “CP programs need to be tailored to each community’s needs” following that up by saying that “standards pushes towards one-size-fits-all.” Personally, I consider EMS to be one of the greatest case studies of how a lack of standards can negatively affect an industry.
As it stands now, any system can throw a medic in a fly car, put them on the street, and have them knock on somebody’s door to ask if they are taking their medication properly and call it a Community Paramedicine program. Maybe Community Paramedicine can be used as another means to differentiate EMS based EMS from fire-based EMS and further show the value of having a single role paramedic protecting a community over somebody who wears two hats. We will never know though if we don’t better define what a CP is, and what we expect them to do.
Community Paramedicine might not be right for Justin’s system, and it might not be right for a lot of systems. Heck, it might not be right for some of the ones that currently have programs but that does not mean that it does not have a place in our industry. The fact is though that there needs to be additional training to make it affective, and there need to be standards that a system must live up to in order to provide the service.
One could easily say that as it stands today, CP programs are far from perfect, but what in this industry cannot be described that way? When compared to the rest of the medical world, effective prehospital care not centered around just transporting a patient to the hospital is barely in its infant stages. It has a lot of growing and developing to do, and the standards need to be set while we are still at the ground floor. Otherwise we end up as we do with too many cooks in the kitchen as we do with so many other things in this industry.
Finally, I just want to thank Justin for sharing his thoughts. I am sure that he will read this with a smile on his face and maybe even post a comment below, and I encourage anyone else who checks this out to do the same. That is one of the best things about this online EMS community that we have formed, everyone is entitled to share their opinion. So, have at it!
Could it be that Community Paramedicine is too important to be left to an industry that is struggling with standards and education for what it already does? I know for my system (outside of the USA), I refer patients to GP’s, or even tell people you don’t need a ride from me and I run an emergency ambulance. However, I have been given extra education, a set of well thought out guidelines, and can call our medical director if needed. All responders at my level, regardless of paid/ volly. have that same education. When I worked in the USA, my education for a similar title was no where near what it is now, and I never would have thought about not taking someone to the ER. Even some of the higher qualified responders didn’t even dare think to refer or leave at home. I know that it always falls back to education and how to implement better education, but it has to start somewhere. Could CP be a place to do it if our industry wants to keep it?
I have three words for you: training, training, training. As much as I thought I would disagree with Justin in a cursory read of his post I find myself agreeing with him upon deeper reflection. Having come from a busy urban paramedic role in Alameda County I then trained for remote paramedic deployments. The HSE Remote Medic (Health and Safety Executive) training in the UK is geared toward turning experienced street medics into primary care/emergency care paramedics in remote locations. I also trained as a Remote Medic for deployment with the US armed forces in Afghanistan in much the same capacity. It has been my experience that the paramedics that undertake these deployments are perfectly suited for combining the primary care role with emergency response and treatment – much more so than the nurses and PAs who were deployed in a similar function. The paramedics have the inquisitive problem solving skills along with the ‘big sick – little sick’ evaluation process that is perfectly applicable to these environments.
During these deployments I have acted as primary care for thousands of deployed personnel in remote locations with minimal diagnostic abilities while running a remote clinic with just one other medic and a PA available via land line. We have treated everything from UTIs, kidney stones, TB outbreaks with quarantine measures, traumatic injuries galore with sutures tetanus shots and anti-biotics, INDs, and septic shock. We have flown out our active MIs, AAAs, DVTs, CVAs, etc. It is the inherent ability of the ‘Medic-mindset’ that thrives in these environments after having the appropriate training and experience.
When I looked at the advancement of the Community Paramedic program I was initially excited to see these Remote Medic skills starting to come home to the US. Yet, without further training the average street medic will fail miserably in these situations. I would not trust myself with ‘catch and release’ responsibilities or ED to clinic redirection three years ago even as an experienced Paramedic Supervisor in a highly demanding system. With the mindset of the street medic being ‘everyone goes to the ED’ or they AMA they limit their diagnostic and intuitive abilities as practitioners. Further training can hone a competent street medic into a highly versatile and effective component of the out of hospital medical community.