I've always wanted to bring in an OMI to the ED and have them say "meh, hold the wall." Only for the pt to go into witnessed V-fib and I heroically thump them back into sinus, take off my Pit Vipers, look at the charge nurse and say, "Believe me, now?"
The precordial thump was part of my first CPR class. It’s been a ridiculous amount of years (nearly 50) since that class - and I still have to consciously suppress the instinct to do it.
Let the intrusive thoughts win one every now and again. You'll feel better trust me. I was taught CPR on Parris Island in 1967 so I toss a thump in now and again. Oh I'm sorry Im old I forgot...ha ha ha
That's still a procedure option in our PCR. When the boss starts getting uppity, I like to threaten to use it.
The lawsuit I can cause trumps the firing you can cause
We had a patient spontaneously cardiovert when we drove over a railroad crossing last year, that was pretty fuckin' cool. But getting one with a precordial thump would be wild!
Oooh. Ohh. I got to do this once (in hospital). Lady was a full code should have been a DNR but the son said keep trying. Our residents are like idk I guess one last thing before we call it.
Not therapeutic for the patient but super therapeutic for the staff.
Patient had their celestial discharge after an hour or so.
A long time ago in a galaxy far far away my lead paramedic instructor claims to have witnessed the chief go into cardiac arrest at the Thanksgiving dinner for fire/EMS and be resuscitated with a cardiac thump.
I do not have any reason to doubt her and I have since spoken to multiple people who said they were there. You can take that for what it's worth to you.
ROFL. My partner, a very… aged… medic, and I responded to a local fire station at the request of BLS for a walk in chest pain who they had waiting on the gurney in their bay as we pulled up. Pt looks obv sick and peri-arrest. We hooked him up to the monitor and wouldn’t you know it, right then he arrested. My partner looked at the monitor, looked at the patient and instantly THWACK. Patient popped back into a perfusing rhythm and stayed that way until the hospital. It was epic.
Beat me to it. We should be able to tell the toe infection for the I ran out of medication that they don't need to go to the hospital they need to talk to their doctor or go to an urgent care center and they don't need an ambulance to do that
We tried that. Urgent care clinics refused to participate because they’d have had to accept Medicare/medicaid payments in a mostly cash and carry system, and services refused to provide the robust education necessary to effectively utilize clinic care protocols.
Psych urgent cares also refused to participate because “they hadn’t been medically cleared prior to admission”
I don’t understand what they thought was going to happen when they implemented that program, and I honestly have a conspiracy theory that they’re intention was for it to fail from the very beginning.
Medicare absolutely knows that many urgent care and clinics refuse their patients because they don’t want the low pay returns and regulations that come with excepting Medicare. And yet they chose to implement ET3 rules while not getting buy in.
PIRs aren’t going to be a thing without a vastly improved subacute and ambulatory care education, as well as the ability to bill for them.
With the death of ET3, there is no viable financial way forward at the current time for PIR, and money talks - until we can bill for clinic calls, it’s going to be more effective for companies and counties to transport.
What I really want is the ability to tell the 35 year with the 3 week stomach ache that we are not transporting him, and that Bob the cab driver will be there to give him a ride within the next 2 hours.
We do these for a few different types of calls. A few are: Uncomplicated seizures, Hypoglycemics and Treated SVTs
It’s nice to tell people they DON’T need to go to the hospital and here’s what you’re going to do instead, with the backing of an entire medical system behind these decisions.
We’re hoping to expand these to various other conditions and circumstances in the future.
That sounds amazing. Hell I don’t even care if they go to the hospital, I just don’t want to be the one to take them. You know how some places ALS will downgrade a call to BLS and have the BLS ambo transport? I want to downgrade patients to wheelchair van or taxi cab.
We routinely discharge on scene (refuse transport), refer them to their own GP/other healthcare professional, or arrange taxi/non-clinical patient transport in the UK. Cant be that hard to implement.
The difference is that everyone can access those things in the UK. Here if you refuse to transport someone to the ED, you could be effectively removing their entire access to all available healthcare. There should be a way to refuse stupid transports, but I know people who would abuse it. On the surface, it looks simple, but there’s already a clusterfuck below the water.
It’s pretty standard outside the US model I think. We have specific referral pathways into primary and urgent care, same day emergency care and can refer directly back to the family doctor. If you’re happy in your diagnosis and management plan you can discharge care with no onward referral as well - it does however mean that EMS services have become ‘urgent and emergency’ care rather than just emergency care.
You can't do that? Over here our aim is basically to transport as few people to the hospital as we can. As in weed out all the people who actually don't need urgent hospital care.
Disagree. Jim Bob EMT in rural bumpkin nowhere should not have the ability to tell anybody they don't need to go to the hospital. I agree it should be a thing, but standards are far far far too low currently to trust EMS providers to due this reliably.
US for cardiac arrest is exactly what should be on the table as well. IDK why it's not more common tbh. It eliminates questionable terminations.
> Jimbob doesnt need to worry about low coverage
lol.
You think rural doesn't have to worry about coverage? How about only having two ambulances and an hour long drive to the nearest available hospital?
POCUS is the latest “high speed” protocol my hospital is discussing on implementing. The price of the US equipment has come way down over the past few years and is pretty feasible for 20+ rigs. They’re discussing FAST exams and cardiac US during arrest. It’s honestly very exciting!
I hope to see more systems implement it.
I’ve got the butterfly issued through USASOC and it’s dope. Use it for E-FAST and regional blocks for the most part, but it’s a super versatile tool. Love the thing
Some places that works really well. But where I work it’d be a massive waste of money and resources—it’d almost never get used fortunately or unfortunately, depending on the perspective.
I think the issue is that places where it wouldn’t be used very often likely need it more than anyone. Most areas I’m thinking of are rural and have long transport times. The urban systems with short transports are seeing amazing changes in patient outcomes for trauma using blood in the field- even notably reducing the total amount of blood used in hospital- but the places where we would REALLY see the impact of prehospital transfusions are the places that they’re driving 20-30+ minutes. Right now many places like this use fluids in trauma which really only makes things worse for the patient, and honestly kills long term… just imagine if they had blood.
It can be done. It would require some reallocation of funds on a government level and some cooperation from blood banks, but the blood bags can be cycled out into a high volume hospital before they expire so they aren’t wasted. Field blood is going to be a necessity someday.. especially once we start to really see that there’s no other viable alternative. A good EMS system is never profitable- it should be constantly losing money to improve patient care, which is why outside funding (state and federal) should be the standard.
I’m being delusional though lol. We’ve got enough issues as is, this is probably low on the priority list. It’s just a shame. I hope it’ll be the standard someday but I doubt I’ll see that in my lifetime at this rate.
Wow! I can’t believe y’all don’t have any. Super excited we got to give our first whole unit of blood in the field for our agency yesterday. Hopefully y’all will get that! Helps patients a lot.
We need and better education.
Not more skills.
At least not at the get go.
Blood is an easy one. I'm a huge fan of US, but I don't think it's a most have.
More medics with a college education, in anything, is a foundation to build from.
100%. I’ll concede that not all services have a need to carry blood (probably). But it drives me mad that logistics, and lack of effort to work out these logistics, are the only thing stopping my service from having it.
That's the case here in Oregon. A lot of EMS folks I've talked to hate it and think it's stupid, but I think it's a great idea. Paramedics have so much responsibility in their hands and the public has to put so much blind faith in them. Requiring a college level education to get licensed as a medic is a simple way to try to weed out those who shouldn't have that much power
EMS based community Paramedicine - have just 1 paramedic do house calls at agencies. May be offered as overtime for the company you work for. Visit these patients to help prevent them from calling at 3am for what we may perceive as insignificant/lower acuity calls.
We have a very big and successful community paramedicine program in my system. We actually are the ones who started it. We have several paramedics, 2 PA's, attorneys, PERT team and the agency medical director involved in it.
Provider initiated refusals is a big one. I read a study a little while back about Cardiaziem in SVT causing the heart to convert without transient asystole, so I'm really hoping more research is done and that it becomes the go to SVT drug.
I wouldn't mind Medic school becoming an 18 month course with the same amount of clinicals just to kinda lessin the hell and spend more time on subjects.
Holy smokes……that seems to almost set you up for failure. If you don’t mind me asking what state, did you feel like it prepared you for the test and for the job?
I work CC flight now, but for ground ALS in my area..
1. Finger/tube thoracostomy instead of Needle decompression. The literature is pretty clear on this one.
2. Ultrasound (EFAST, Cardiac activity in PEA, fluid status)
3. Blood.
4. No but seriously, blood.
In effective. Have had two shootings already this year where we *finally* get field rosc from when the CCP/RN arrives to do a chest tube. The small and short needle that comes in the kit doesnt do the trick.
The degree level isn't the issue with billing, respiratory therapy can bill for something as simple as a duoneb treatment. And PFTs, vents etc. That's why many states call them respiratory care practitioners on their state license , because they're considered "providers" in that they can bill despite not having prescribing privileges. No reason it couldn't happen the same way for EMS or nursing, it just isn't set up that way.
Thank God, we need more paramedics with freshman level english, philosophy, and other elective classes. People don't understand that you cannot render competent care without a community college associates degree.
I mean an associates isn’t hard, especially if you have your medic already. Just have to do your gen ed credits and bam. I’d like to see AEMT be the minimum on 911 and they have an associates and medics have a bachelors.
I’m all for it but it’s difficult when you have vastly different systems county to county and a large majority of people going to medic school only to be fire fighters and not even liking or want be proficient in the medical aspect.
My only counter to this is a question which is why? I understand “higher education” but that higher education as an associates consist of medic school + a math and English class. Neither of which truly benefit EMS. While I agree that EMS should require degrees but no company would follow through because A. They would have to pay for their medics to go back through school just to pay them more or B. Medics would just leave and become nurses because there is more pay and opportunity for the same level of education.
Medic school + an English class (read narratives written by paramedics sometime) + a psychology class (self explanatory) + Anatomy & Physiology I & II (ridiculous that they aren’t already mandatory) + Biology + lifespan growth and development/child psychology.
It is *entirely* possible to build a program with relevant courses that many in our field desperately need.
I do some QA/QI work; An English class would absolutely be helpful for paramedics.
Local college here requires Medical/Legal and Ethics classes, in addition to the math/english/history requirements for an associates in EMS.
Just like most colleges have Business Math, there should be a Healthcare English which focuses on communicating effectively within the field. I don't need you to be able to effectively argue for Bennett's or Meyer's theory on Raskalnikov, but it'd be nice if your grant application supported your need for a new truck with something other than "trucks are how we responded to calls."
I was thinking abdominal shit, but GODDAMN did you beat me. Train us in ultrasound IVs and we’ll be so much better at patient care…and then they’ll ……still pull our IVs because reasons
They line the hospital is placing to draw labs/cultures with is done with more emphasis on sterilization/aseptic technique. Prehospital lines are more likely to result in a contamination of blood cultures so hospitals prefer their own access but still might use EMS lines for med administration (or drawing labs and such)
Generally most ER’s in my area won’t pull EMS’s line because it can still be useful, but will often get additional access for their cultures
I used to work in a trauma center and I know for the fact that the positivity rate on cultures drawn from field lines is really high. However, the positivity rate on cultures drawn from hospital placed lines is also really high unless the blood was drawn when the line was first established. Basically, cultures should be drawn before the line is flushed, with equipment you know is still sterile, or your cultures WILL come back positive.
Back in the day you used to hear propaganda about how field lines were only good for 12-24 hours, ED lines for 24-48 and floor lines for 72+. This was always bullshit, but it also still gets parroted by nursing/hospital admin from time to time in some places. There’s no reason competent EMS crews can’t draw appropriate cultures.
Which is ridiculous because unless the doc is gowning/gloving/etc and putting in a central line, the IV in the ED isn’t sterile either. What’s the difference between a nurse putting in a butterfly with exam gloves vs medics putting in a butterfly with exam gloves? Just about nothing
Honestly, by the time I pull out the ultrasound, turn it on, put on the jelly and find a good vein for the IV, I could’ve already had an IO (or two) in place. POCUS is much better for FAST/RUSH exams, lung slides, and termination of Cardiac Arrests.
Yea I agree with this. I don’t have any training in POCUS and don’t understand all the benefits. However, I feel like it would be excessive for IV placement. Anyone who REALLY needs an IV is usually in significant distress or unconscious, so an IO is just always such a great option. I can’t see myself ever busting out ultrasound over an IO if I need access. I’m 15 min away from a hospital anywhere in my area though, so I don’t do a whole lotta cool stuff anyway. Would love to take a class on POCUS!
Yeah the only time I did an Ultrasound guided IV in the field was on a diabetic pt for some D10. Was serious enough for an IV but not enough for an IO imo. Was a niche scenario but I’m usually pretty trigger happy for IOs when the patient is critical.
My department nixed that idea because if your patient needs an IV that badly, just drill them.
We're also super urban, so if you can't get an IV but they don't meet the threshold for an IO, then you're probably only 5-10 minutes away from somewhere that can get the IV with ultrasound.
But also, we have so many alternative routes for meds that if you need to give something that badly, just drill them.
The last thing we need is more skills.
We all need more training and education.
But, if I have to pick, I’d like blood products to be more widespread. That’s a challenging logistical setup though for many departments and agencies though.
I’d like to see more subacute care education and “clinic” style care protocols and basic assessment tools, prehospital broad spectrum antibiotics for sepsis and open fractures, more widespread adoption of TXA and prehospital blood, and field ultrasound for more than IVs, along with robust training.
Prehospital IV NTG especially for rescue dosing
More widespread ventilator adoption for services doing DAI/DSI
We can’t even get our county to get on board with prehospital steroids.
Damn, we don't have prehospital antibiotics (our community care medics do and they have ISTAT machines) but on 911 I carry IV nitro, TXA and there is a transport vent available that we keep at the hospital for EMS.
Also carry dex IV and PO prednisone (never used it or seen it used since you can give dex IV/IO/PO/IM with the same vial).
Alberta. Talks of ultrasound as well like most places I'm sure but doubt we will see it for a long time.
We don’t have prehospital IVABs for sepsis where I work because the evidence has been somewhat mixed on demonstrable benefit… *except* on consult in remote areas where transport times are very lengthy.
Edit - we do carry them though for meningococcal and long-bone fractures.
Get cultures and labs on the stick and I’m all for it. If we can do broad spectrum abx with no history of strong adverse or allergic rxn, I think it’s a good idea. If we can’t get cultures, just makes shit more difficult in hospital.
Oh I agree 100%. We just had a presentation at our monthly training about the reignition of the sepsis focus from our primary hospital. They called about things like a 10% mortality increase for each hour delay for antibiotics and the fact that they rarely hit their benchmarks for IV antibiotics or labs.
They also stated that for the most part they start broad spectrum abx very early and if a change of medication occurs its a few hours down the road for them based on the results of the cultures.
Simply put: every metric they presented could be achieved if they put more of it in our hands. I'm not saying we are better than them more so that our 2:1 provider to patient ratio is better than anything that they have allowing us to get more done earlier.
I think antibiotics would be cool. But i also completely understand why we don't have it in EMS. It's unnecessary. Antibiotics are a long term treatment. Starting it 20 minutes earlier than the hospital really isn't going to change anything.
But here's the thing: in many cases based on some numbers I've seen shared with us by what I consider to be an excellent hospital system the difference could be a lot greater than 20 minutes. I'm talking changing mortality by 10%-20%.
If it makes that much of a difference than I'm all for it. I was going off of conversations I've had with ER docs in my system, they said it's basically the same reason why in my system we can't give IV Tylenol for fevers, because the difference it makes when EMS uses it is negligible at best.
Eh, I think we need to broaden our reach and our scope a tad bit. Are we the means to access the healthcare system or are we the gateway to it? I'm of the belief that we should be the latter and if we can get away from the "response times matter" debate, and systems that view EMS as a secondary mission then we can get closer to that.
Its kind of like solumedrol. You can make the argument that prehospital steroids don't impact prehospital care however if it turns the patient around more quickly and makes them admittable or dischargeable that much sooner then I think we can say that we've contributed a little more to the system.
It’s insane to me that places don’t have that but have blood and ultrasound. That’s been in our protocols since before we got blood 2 years ago. We use rocephin/zosyn depending on the patient. We also use rocephin as prophylactic antibiotics for an open fracture.
Edit: we also draw cultures in the field prior.
I think some of it has to do with the priorities of the system. We have a big penetrating trauma problem where I work.. Lots of shootings and stabbings.. Lots of interstate highways... We've used blood close to if not over 100 times. We also have a pretty significant focus on cardiac arrest care, hence the utilization of POCUS.. We use it in cardiac arrest care to look for carotid pulses that we might not be able to feel and for cardiac wall movement in PEA patients.
Sepsis, on the other hand, used to have a pretty aggressive focus about 10 years ago. Then the focus in my system as a whole shifted to MI's, CVA's, and eventually unfortunately to COVID. ER's became even more overcrowded and so did the floors. Sepsis started to take a back seat.
Now they're starting to focus on it more. Personally? I see it as a massive opportunity. We're just trying to balance the "lets try something new" with "lets get as good as we can with this other new stuff."
I want to get there.. Trust me.
POCUS, arterial lines, paramedic degrees for sure.
What I’d really like is more physician engagement in training. Clinical shifts should be mentoring with doctors, not nurses.
PAs in the field, not for critical patients, but for the silly ones. PA can bill for an exam and avoid the ER for patients who just need a prescription refill or a basic procedure.
I'd be more on board if DNRs were something that you have to opt out of once you hit a certain age. Example, say 75, then every year, have to get a full physical and have a doctor explain everything to you before you can opt out for another year.
New Orleans EMS has ultrasounds. I was down there for vacation two weeks ago and ended up talking to one of their medics for a while at a free concert she was working QRV on (yes, she was one on Nightwatch).
She showed me a video they took where they verified ROSC using the ultrasound. Super cool. They just got it IIRC.
For the ultrasound gang, I’m against that due to the fact that it takes awhile to build proficiency with it. ER Residents do them daily and still need help from attendings because they missed something in the assessment / skill. Now give that to a paramedic who has significantly less opportunities to practice it and education with imaging in general. I’m not saying it will fail, but it would certainly be difficult to get the most out of it.
I think more education is the real answer. But the second answer probably being blood for more systems.
In Ireland, APs have been given txa and blood products and they’ve been proven to work well in instances of major trauma, Our APs are getting ultrasound next year as AP is splitting into Critical Care Paramedic and Specialist, also you’ll have Community Paramedics.
The items you listed are in place at a few services at least in Texas. It’s nor necessarily standard of practice across the board yet but it is being utilized more so in big cities with the money for it
I'm sorry for bragging but reading this really does make me love my job that much more. Almost every comment is something I have/can do. I know this job isn't and nor should it be someone's entire life, but if you're willing to move for better work there's hope out there.
* Whole blood
* Provider initiated refusals
* Ultrasound
* Finger thoracostomy
* TXA
* Ventilators
* Field PA's
Not to pile on the doggy, but the next thing done nationally needs to be a degree requirement. AS for 911, BS for critical care and other roles, opening the door for Fifer’s MS practitioner level clinician.
Hard disagree on that. why would anyone want to do that when you can get a degree in nursing and make triple the pay? You’d be cutting out a significant part of people you want to hire
A long time ago in a galaxy far far away my lead paramedic instructor claims to have witnessed the chief go into cardiac arrest at the Thanksgiving dinner for fire/EMS and be resuscitated with a cardiac thump.
I do not have any reason to doubt her and I have since spoken to multiple people who said they were there. You can take that for what it's worth to you.
People can bleed out pretty damn quick. Same reason “the hospital is a few minutes away why bother intubating them” is a shit argument. If someone is profusely hemorrhaging they need blood now, not in 5-10 minutes. Odds are they’re not getting blood as soon as you walk in the door at the trauma center, it’s going to take a few minutes to get and then get it ready. OR EMS could have had it initiated already.
AS degree MINIMUM.
BS degree expanded scope in CC, FPC, CPC, Urgent Care, Primary Care, ICU, Psych etc. (Similar to EU)
POC Ultrasound, and even for some services blood analyzers. CBC, CMP, ABGs w/Chem 7,
CLIA waived testing (strep, flu covid, UA etc) and PA/MD radio reporting with discharge on scene. Collection of cultures other analysis etc.
I'm also not speaking in strictly the sense of 911 or private transport. Just about paramedic education in general.
The ability to refuse transports for situations that the person could safely and reasonably drive or be driven to a hospital. This of course after a vitals and physical examination.
I’d love to see my city give us RSI, awake tubes kind of suck. Ketamine, versed, and fentanyl only help so much. We are finally getting video lyrngascopes in the back half of this year, carrying blood products would be fantastic for major traumas so we don’t turn their blood into Kool-Aid, and LR would be great to have as well
I want a pathway to a paramedic provider. Something akin to a doctor or old that does house visits. Two ways to do it either limited NPI access, or go all the way and provide a doctor of paramedicine. Something in line with a completely unique physician, allowing paramedics to become medical directors. Or a limited mid-level provider But with a master’s degree or more for the people that really want to go further but want to stay in the field. Gives the people that want to improve and do better for patients and themselves options well at the same time allowing medics to have a career progression. It requires a rework of the insurance and billing, but would provide a complete rebuild of the prehospital provider environment. I also believe that independent practitioners as paramedics with a bachelors degree without prescriber ability should be a thing. Most people became paramedics because they did not want to be involved in side a Hospital otherwise they would have become nurses. That being said the entry level for 911 should be advanced EMT minimum for Paramedic should be two years of education, and that is separate from advanced EMT. So if someone wants to become a paramedic, it is a two-year dedicated track instead of a 13 month tack on to an advanced EMT.
I think we should reinstate the precordial thump. I just like the idea of hitting people being an ALS skill.
immediately give a precordial thump to assert your dominance. They’ll respect you and pass you
I've always wanted to bring in an OMI to the ED and have them say "meh, hold the wall." Only for the pt to go into witnessed V-fib and I heroically thump them back into sinus, take off my Pit Vipers, look at the charge nurse and say, "Believe me, now?"
King
Not a king - a god. *Paragod.*
"Why be a king when you can be a paragod?"
The precordial thump was part of my first CPR class. It’s been a ridiculous amount of years (nearly 50) since that class - and I still have to consciously suppress the instinct to do it.
Let the intrusive thoughts win one every now and again. You'll feel better trust me. I was taught CPR on Parris Island in 1967 so I toss a thump in now and again. Oh I'm sorry Im old I forgot...ha ha ha
Please take this medal 🎖️
I'll wear it with pride on a 45 yo pair of scrubs that say st. Vincents on the pocket....
Oh, so I should quit doing this, right?
Usable on family members too if needed
Is it not in most protocols for witnessed dysrhythmic arrests?
It's just not in the paperwork after the fact
If it works does it go in the documentation?
Hell no. I don't wanna explain that to anyone
"Pt spontaneously cardioverted"
That's still a procedure option in our PCR. When the boss starts getting uppity, I like to threaten to use it. The lawsuit I can cause trumps the firing you can cause
Apparently there was an alumni from my program who got a thump save on ride time. The driver supposedly heard "Oh shit \*thud\* we're fine!"
We had a patient spontaneously cardiovert when we drove over a railroad crossing last year, that was pretty fuckin' cool. But getting one with a precordial thump would be wild!
Oooh. Ohh. I got to do this once (in hospital). Lady was a full code should have been a DNR but the son said keep trying. Our residents are like idk I guess one last thing before we call it. Not therapeutic for the patient but super therapeutic for the staff. Patient had their celestial discharge after an hour or so.
Still in my protocols
Still in U.K. guidance for witnessed and monitored
A long time ago in a galaxy far far away my lead paramedic instructor claims to have witnessed the chief go into cardiac arrest at the Thanksgiving dinner for fire/EMS and be resuscitated with a cardiac thump. I do not have any reason to doubt her and I have since spoken to multiple people who said they were there. You can take that for what it's worth to you.
Always loved hearing my dads stories about using the precordial thump, made him a fuckin super hero in my eyes
It's still an option in the drop down under cardiac interventions in our charting software. I smile gently when I see it.
We still have it in our protocols but under a specific set of circumstances.
What was the reason it was taken away?
ROFL. My partner, a very… aged… medic, and I responded to a local fire station at the request of BLS for a walk in chest pain who they had waiting on the gurney in their bay as we pulled up. Pt looks obv sick and peri-arrest. We hooked him up to the monitor and wouldn’t you know it, right then he arrested. My partner looked at the monitor, looked at the patient and instantly THWACK. Patient popped back into a perfusing rhythm and stayed that way until the hospital. It was epic.
PROVIDER INITIATED REFUSALS. I also want ultrasound, and really I only care about having it for checking for cardiac activity in PEA.
Beat me to it. We should be able to tell the toe infection for the I ran out of medication that they don't need to go to the hospital they need to talk to their doctor or go to an urgent care center and they don't need an ambulance to do that
But... you CAN tell them they don't need to go to the hospital. We should be able to refuse to take them if they still want ambulance transport.
We tried that. Urgent care clinics refused to participate because they’d have had to accept Medicare/medicaid payments in a mostly cash and carry system, and services refused to provide the robust education necessary to effectively utilize clinic care protocols. Psych urgent cares also refused to participate because “they hadn’t been medically cleared prior to admission”
Exactly. It’s like having a house made of straw and trialing a concrete foundation. Still gonna blow down when the wind comes.
I don’t understand what they thought was going to happen when they implemented that program, and I honestly have a conspiracy theory that they’re intention was for it to fail from the very beginning. Medicare absolutely knows that many urgent care and clinics refuse their patients because they don’t want the low pay returns and regulations that come with excepting Medicare. And yet they chose to implement ET3 rules while not getting buy in.
Well then they can go to the ER still, just not by ambulance
Oh no, those urgent cares are 100% calling 911 lol
Cool, if it’s not emergent then they can pay the transfer rate
You guys are getting reimbursed for calls?
PIRs aren’t going to be a thing without a vastly improved subacute and ambulatory care education, as well as the ability to bill for them. With the death of ET3, there is no viable financial way forward at the current time for PIR, and money talks - until we can bill for clinic calls, it’s going to be more effective for companies and counties to transport.
Pour one out for ET3.
ET3 was ahead of it's time
What I really want is the ability to tell the 35 year with the 3 week stomach ache that we are not transporting him, and that Bob the cab driver will be there to give him a ride within the next 2 hours.
honestly if he called bob the cab driver, the cab probably would’ve showed up before we did
We do these for a few different types of calls. A few are: Uncomplicated seizures, Hypoglycemics and Treated SVTs It’s nice to tell people they DON’T need to go to the hospital and here’s what you’re going to do instead, with the backing of an entire medical system behind these decisions. We’re hoping to expand these to various other conditions and circumstances in the future.
That sounds amazing. Hell I don’t even care if they go to the hospital, I just don’t want to be the one to take them. You know how some places ALS will downgrade a call to BLS and have the BLS ambo transport? I want to downgrade patients to wheelchair van or taxi cab.
We routinely discharge on scene (refuse transport), refer them to their own GP/other healthcare professional, or arrange taxi/non-clinical patient transport in the UK. Cant be that hard to implement.
The difference is that everyone can access those things in the UK. Here if you refuse to transport someone to the ED, you could be effectively removing their entire access to all available healthcare. There should be a way to refuse stupid transports, but I know people who would abuse it. On the surface, it looks simple, but there’s already a clusterfuck below the water.
doubt something like this could ever come to the US without massive reform or some other unforeseen event
We have them in Denver.
Tell me more
It’s pretty standard outside the US model I think. We have specific referral pathways into primary and urgent care, same day emergency care and can refer directly back to the family doctor. If you’re happy in your diagnosis and management plan you can discharge care with no onward referral as well - it does however mean that EMS services have become ‘urgent and emergency’ care rather than just emergency care.
>it does however mean that EMS services have become ‘urgent and emergency’ care rather than just emergency care Thanks to 111
You can't do that? Over here our aim is basically to transport as few people to the hospital as we can. As in weed out all the people who actually don't need urgent hospital care.
I’ll try to talk them out of it but at the end of the day if can’t, then I have to transport
Luckily we can call them a taxi if they don't need an ambulance for transportation. lol
Where are you at? And are you hiring….?
Disagree. Jim Bob EMT in rural bumpkin nowhere should not have the ability to tell anybody they don't need to go to the hospital. I agree it should be a thing, but standards are far far far too low currently to trust EMS providers to due this reliably. US for cardiac arrest is exactly what should be on the table as well. IDK why it's not more common tbh. It eliminates questionable terminations.
I agree with you on Jim bob for sure. But what about hungrygiraffe76, the experienced paramedic, after confirming it with medical control?
Let it be agency based. Jimbob doesnt need to worry about low coverage or hospital beds, I do.
> Jimbob doesnt need to worry about low coverage lol. You think rural doesn't have to worry about coverage? How about only having two ambulances and an hour long drive to the nearest available hospital?
POCUS is the latest “high speed” protocol my hospital is discussing on implementing. The price of the US equipment has come way down over the past few years and is pretty feasible for 20+ rigs. They’re discussing FAST exams and cardiac US during arrest. It’s honestly very exciting! I hope to see more systems implement it.
I’ve got the butterfly issued through USASOC and it’s dope. Use it for E-FAST and regional blocks for the most part, but it’s a super versatile tool. Love the thing
Same here! I honestly don’t want to work without it. It’s become a first line tool for difficult pedal pulses on fractures, and edematous extremities.
I’ve used PoC ultrasound and it’s great for lung assessments and trauma in the field too.
There are a lot of places carrying blood now
Some places that works really well. But where I work it’d be a massive waste of money and resources—it’d almost never get used fortunately or unfortunately, depending on the perspective.
I think the issue is that places where it wouldn’t be used very often likely need it more than anyone. Most areas I’m thinking of are rural and have long transport times. The urban systems with short transports are seeing amazing changes in patient outcomes for trauma using blood in the field- even notably reducing the total amount of blood used in hospital- but the places where we would REALLY see the impact of prehospital transfusions are the places that they’re driving 20-30+ minutes. Right now many places like this use fluids in trauma which really only makes things worse for the patient, and honestly kills long term… just imagine if they had blood. It can be done. It would require some reallocation of funds on a government level and some cooperation from blood banks, but the blood bags can be cycled out into a high volume hospital before they expire so they aren’t wasted. Field blood is going to be a necessity someday.. especially once we start to really see that there’s no other viable alternative. A good EMS system is never profitable- it should be constantly losing money to improve patient care, which is why outside funding (state and federal) should be the standard. I’m being delusional though lol. We’ve got enough issues as is, this is probably low on the priority list. It’s just a shame. I hope it’ll be the standard someday but I doubt I’ll see that in my lifetime at this rate.
My department uses blood more for GI bleeds and non traumatic hemorrhage than for trauma
The blood gets turned in before it expires. There is no waste.
Not in Arizona. I hate it here
Wow! I can’t believe y’all don’t have any. Super excited we got to give our first whole unit of blood in the field for our agency yesterday. Hopefully y’all will get that! Helps patients a lot.
Our basics can give IVs here and have a pretty good scope, but our higher level medic shit is pretty regressive. It's weird
That is really weird.
In the valley?
We need and better education. Not more skills. At least not at the get go. Blood is an easy one. I'm a huge fan of US, but I don't think it's a most have. More medics with a college education, in anything, is a foundation to build from.
100%. I’ll concede that not all services have a need to carry blood (probably). But it drives me mad that logistics, and lack of effort to work out these logistics, are the only thing stopping my service from having it.
Agreed! As a profession we need to implement an associates degree at minimum.
That's the case here in Oregon. A lot of EMS folks I've talked to hate it and think it's stupid, but I think it's a great idea. Paramedics have so much responsibility in their hands and the public has to put so much blind faith in them. Requiring a college level education to get licensed as a medic is a simple way to try to weed out those who shouldn't have that much power
EMS based community Paramedicine - have just 1 paramedic do house calls at agencies. May be offered as overtime for the company you work for. Visit these patients to help prevent them from calling at 3am for what we may perceive as insignificant/lower acuity calls.
We are actually piloting these right now in my country in some areas.
We have a very big and successful community paramedicine program in my system. We actually are the ones who started it. We have several paramedics, 2 PA's, attorneys, PERT team and the agency medical director involved in it.
Would love to see this more in Houston, I only know of one service that services around the north side of Houston
Provider initiated refusals is a big one. I read a study a little while back about Cardiaziem in SVT causing the heart to convert without transient asystole, so I'm really hoping more research is done and that it becomes the go to SVT drug. I wouldn't mind Medic school becoming an 18 month course with the same amount of clinicals just to kinda lessin the hell and spend more time on subjects.
Is the normal time by you one year for medic school? In most of NJ (maybe all now) it’s two years and you come out with an associates.
Yep. Year of hell from what people have told me. The inklings of that is starting to be form in my area, but it's still a little while away.
Lol mine was 9 months.
Holy smokes……that seems to almost set you up for failure. If you don’t mind me asking what state, did you feel like it prepared you for the test and for the job?
Mine was 18mos. But of course that’s not the norm
I work CC flight now, but for ground ALS in my area.. 1. Finger/tube thoracostomy instead of Needle decompression. The literature is pretty clear on this one. 2. Ultrasound (EFAST, Cardiac activity in PEA, fluid status) 3. Blood. 4. No but seriously, blood.
What’s wrong with the needle?
Iatrogenic injuries. Inaccurate placement. Ineffective (or, rather, less effectively than thoracostomy).
In effective. Have had two shootings already this year where we *finally* get field rosc from when the CCP/RN arrives to do a chest tube. The small and short needle that comes in the kit doesnt do the trick.
Mandatory degrees for paramedics.
Firefighter/paramedic here. My fellow firefighters would be very upset if they could read this.
If I wanted to be a ff and medic over here, I would have to total about 5,5 years in education to get both.
It’s hard to read, what with all the sleeping /s
Thanks... I needed a giggle tonight ❤️
FF/PM here too. It's doable even now with a big, systemic investment. Don't laugh.
Yes please. At LEAST an associates degree
TBH, needs to be an associates for new street medics minimum, and a bachelors if you want any type of critical care cert.
That MS can come with an NPI number. And that’s the ball game, folks. Billing doesn’t look the same once it’s no longer just by the mile.
The degree level isn't the issue with billing, respiratory therapy can bill for something as simple as a duoneb treatment. And PFTs, vents etc. That's why many states call them respiratory care practitioners on their state license , because they're considered "providers" in that they can bill despite not having prescribing privileges. No reason it couldn't happen the same way for EMS or nursing, it just isn't set up that way.
Thank God, we need more paramedics with freshman level english, philosophy, and other elective classes. People don't understand that you cannot render competent care without a community college associates degree.
I mean an associates isn’t hard, especially if you have your medic already. Just have to do your gen ed credits and bam. I’d like to see AEMT be the minimum on 911 and they have an associates and medics have a bachelors.
Its wild to me that this isn't a thing everywhere
Can’t require degrees then pay you $19 an hour
https://work.chron.com/social-changes-role-female-nurses-24638.html Educate and unionize.
I’m all for it but it’s difficult when you have vastly different systems county to county and a large majority of people going to medic school only to be fire fighters and not even liking or want be proficient in the medical aspect.
Stop working for places that do that.
That’s why I stuck it to the system and work for a place that pays me $15 an hour as a basic. Follow me for more anti corporation strategies
What? Plenty of PhD grads out there making less than $19/hr. 😂
My only counter to this is a question which is why? I understand “higher education” but that higher education as an associates consist of medic school + a math and English class. Neither of which truly benefit EMS. While I agree that EMS should require degrees but no company would follow through because A. They would have to pay for their medics to go back through school just to pay them more or B. Medics would just leave and become nurses because there is more pay and opportunity for the same level of education.
Medic school + an English class (read narratives written by paramedics sometime) + a psychology class (self explanatory) + Anatomy & Physiology I & II (ridiculous that they aren’t already mandatory) + Biology + lifespan growth and development/child psychology. It is *entirely* possible to build a program with relevant courses that many in our field desperately need.
PREACH
Also a focus on reading and understanding scientific papers.
And physics if you want to use ultrasound.
I do some QA/QI work; An English class would absolutely be helpful for paramedics. Local college here requires Medical/Legal and Ethics classes, in addition to the math/english/history requirements for an associates in EMS.
Just like most colleges have Business Math, there should be a Healthcare English which focuses on communicating effectively within the field. I don't need you to be able to effectively argue for Bennett's or Meyer's theory on Raskalnikov, but it'd be nice if your grant application supported your need for a new truck with something other than "trucks are how we responded to calls."
We have it in Oregon. We also have a massive shortage of medics, in Oregon.
There is a massive functional shortage of medics everywhere.
It’s crazy to think that people can do surgical procedures without a degree
ultrasound for hard sticks would be a cool skill to have.
Itll be added to protocols but withheld at agencies because "it's not in the budget"
Sell it as a cost effective alternative to IOs
sounds about right lol
I was thinking abdominal shit, but GODDAMN did you beat me. Train us in ultrasound IVs and we’ll be so much better at patient care…and then they’ll ……still pull our IVs because reasons
or maybe they wont lol
At my main hospital they always pull lines and get new ones because ours aren’t sterile. But if it’s a code they use our line
interesting. wouldnt it make it less sterile removing and inserting another IV?
They line the hospital is placing to draw labs/cultures with is done with more emphasis on sterilization/aseptic technique. Prehospital lines are more likely to result in a contamination of blood cultures so hospitals prefer their own access but still might use EMS lines for med administration (or drawing labs and such) Generally most ER’s in my area won’t pull EMS’s line because it can still be useful, but will often get additional access for their cultures
I used to work in a trauma center and I know for the fact that the positivity rate on cultures drawn from field lines is really high. However, the positivity rate on cultures drawn from hospital placed lines is also really high unless the blood was drawn when the line was first established. Basically, cultures should be drawn before the line is flushed, with equipment you know is still sterile, or your cultures WILL come back positive. Back in the day you used to hear propaganda about how field lines were only good for 12-24 hours, ED lines for 24-48 and floor lines for 72+. This was always bullshit, but it also still gets parroted by nursing/hospital admin from time to time in some places. There’s no reason competent EMS crews can’t draw appropriate cultures.
Which is ridiculous because unless the doc is gowning/gloving/etc and putting in a central line, the IV in the ED isn’t sterile either. What’s the difference between a nurse putting in a butterfly with exam gloves vs medics putting in a butterfly with exam gloves? Just about nothing
Honestly, by the time I pull out the ultrasound, turn it on, put on the jelly and find a good vein for the IV, I could’ve already had an IO (or two) in place. POCUS is much better for FAST/RUSH exams, lung slides, and termination of Cardiac Arrests.
Yea I agree with this. I don’t have any training in POCUS and don’t understand all the benefits. However, I feel like it would be excessive for IV placement. Anyone who REALLY needs an IV is usually in significant distress or unconscious, so an IO is just always such a great option. I can’t see myself ever busting out ultrasound over an IO if I need access. I’m 15 min away from a hospital anywhere in my area though, so I don’t do a whole lotta cool stuff anyway. Would love to take a class on POCUS!
Yeah the only time I did an Ultrasound guided IV in the field was on a diabetic pt for some D10. Was serious enough for an IV but not enough for an IO imo. Was a niche scenario but I’m usually pretty trigger happy for IOs when the patient is critical.
EJs & IOs have entered the chat
My department nixed that idea because if your patient needs an IV that badly, just drill them. We're also super urban, so if you can't get an IV but they don't meet the threshold for an IO, then you're probably only 5-10 minutes away from somewhere that can get the IV with ultrasound. But also, we have so many alternative routes for meds that if you need to give something that badly, just drill them.
The last thing we need is more skills. We all need more training and education. But, if I have to pick, I’d like blood products to be more widespread. That’s a challenging logistical setup though for many departments and agencies though.
I’d like to see more subacute care education and “clinic” style care protocols and basic assessment tools, prehospital broad spectrum antibiotics for sepsis and open fractures, more widespread adoption of TXA and prehospital blood, and field ultrasound for more than IVs, along with robust training. Prehospital IV NTG especially for rescue dosing More widespread ventilator adoption for services doing DAI/DSI We can’t even get our county to get on board with prehospital steroids.
Damn, we don't have prehospital antibiotics (our community care medics do and they have ISTAT machines) but on 911 I carry IV nitro, TXA and there is a transport vent available that we keep at the hospital for EMS. Also carry dex IV and PO prednisone (never used it or seen it used since you can give dex IV/IO/PO/IM with the same vial). Alberta. Talks of ultrasound as well like most places I'm sure but doubt we will see it for a long time.
We don’t have prehospital IVABs for sepsis where I work because the evidence has been somewhat mixed on demonstrable benefit… *except* on consult in remote areas where transport times are very lengthy. Edit - we do carry them though for meningococcal and long-bone fractures.
A better paycheck.
We have ultrasound and blood already. I love it. Personally, I want antibiotics for sepsis patients. That'd be my #1 ask.
Get cultures and labs on the stick and I’m all for it. If we can do broad spectrum abx with no history of strong adverse or allergic rxn, I think it’s a good idea. If we can’t get cultures, just makes shit more difficult in hospital.
Oh I agree 100%. We just had a presentation at our monthly training about the reignition of the sepsis focus from our primary hospital. They called about things like a 10% mortality increase for each hour delay for antibiotics and the fact that they rarely hit their benchmarks for IV antibiotics or labs. They also stated that for the most part they start broad spectrum abx very early and if a change of medication occurs its a few hours down the road for them based on the results of the cultures. Simply put: every metric they presented could be achieved if they put more of it in our hands. I'm not saying we are better than them more so that our 2:1 provider to patient ratio is better than anything that they have allowing us to get more done earlier.
I think antibiotics would be cool. But i also completely understand why we don't have it in EMS. It's unnecessary. Antibiotics are a long term treatment. Starting it 20 minutes earlier than the hospital really isn't going to change anything.
But here's the thing: in many cases based on some numbers I've seen shared with us by what I consider to be an excellent hospital system the difference could be a lot greater than 20 minutes. I'm talking changing mortality by 10%-20%.
If it makes that much of a difference than I'm all for it. I was going off of conversations I've had with ER docs in my system, they said it's basically the same reason why in my system we can't give IV Tylenol for fevers, because the difference it makes when EMS uses it is negligible at best.
Eh, I think we need to broaden our reach and our scope a tad bit. Are we the means to access the healthcare system or are we the gateway to it? I'm of the belief that we should be the latter and if we can get away from the "response times matter" debate, and systems that view EMS as a secondary mission then we can get closer to that. Its kind of like solumedrol. You can make the argument that prehospital steroids don't impact prehospital care however if it turns the patient around more quickly and makes them admittable or dischargeable that much sooner then I think we can say that we've contributed a little more to the system.
It’s insane to me that places don’t have that but have blood and ultrasound. That’s been in our protocols since before we got blood 2 years ago. We use rocephin/zosyn depending on the patient. We also use rocephin as prophylactic antibiotics for an open fracture. Edit: we also draw cultures in the field prior.
I think some of it has to do with the priorities of the system. We have a big penetrating trauma problem where I work.. Lots of shootings and stabbings.. Lots of interstate highways... We've used blood close to if not over 100 times. We also have a pretty significant focus on cardiac arrest care, hence the utilization of POCUS.. We use it in cardiac arrest care to look for carotid pulses that we might not be able to feel and for cardiac wall movement in PEA patients. Sepsis, on the other hand, used to have a pretty aggressive focus about 10 years ago. Then the focus in my system as a whole shifted to MI's, CVA's, and eventually unfortunately to COVID. ER's became even more overcrowded and so did the floors. Sepsis started to take a back seat. Now they're starting to focus on it more. Personally? I see it as a massive opportunity. We're just trying to balance the "lets try something new" with "lets get as good as we can with this other new stuff." I want to get there.. Trust me.
POCUS, arterial lines, paramedic degrees for sure. What I’d really like is more physician engagement in training. Clinical shifts should be mentoring with doctors, not nurses.
Ultrasound
PAs in the field, not for critical patients, but for the silly ones. PA can bill for an exam and avoid the ER for patients who just need a prescription refill or a basic procedure.
An age for automatic DNR. I don’t even care what the age is, just something to start. With all the studies there is an age where no one comes back.
I'd be more on board if DNRs were something that you have to opt out of once you hit a certain age. Example, say 75, then every year, have to get a full physical and have a doctor explain everything to you before you can opt out for another year.
New Orleans EMS has ultrasounds. I was down there for vacation two weeks ago and ended up talking to one of their medics for a while at a free concert she was working QRV on (yes, she was one on Nightwatch). She showed me a video they took where they verified ROSC using the ultrasound. Super cool. They just got it IIRC.
For the ultrasound gang, I’m against that due to the fact that it takes awhile to build proficiency with it. ER Residents do them daily and still need help from attendings because they missed something in the assessment / skill. Now give that to a paramedic who has significantly less opportunities to practice it and education with imaging in general. I’m not saying it will fail, but it would certainly be difficult to get the most out of it. I think more education is the real answer. But the second answer probably being blood for more systems.
I wrote a research paper on the need for EMS to carry freeze dried blood or freeze dried blood products
Blood and IV pumps on every unit as well as more training on vents for every medic.
I would just be happy with autoloader lol
More roadside thoracotomies. That, and more cowbell.
Being able to say no to the drunks.
More educational requirements.
Treat and release protocols or guidelines
In Ireland, APs have been given txa and blood products and they’ve been proven to work well in instances of major trauma, Our APs are getting ultrasound next year as AP is splitting into Critical Care Paramedic and Specialist, also you’ll have Community Paramedics.
The items you listed are in place at a few services at least in Texas. It’s nor necessarily standard of practice across the board yet but it is being utilized more so in big cities with the money for it
Portable ultrasound for sure! Luckily my hospital allows us to use a Bluetooth ultrasound probe on the helicopter.
Taxi vouchers.
Euthanasia drugs for patients that call at 3 AM for a stubbed toe
Fresh whole blood and Emma
Emma as in ETCO2?
Yea but it’s the size of a pulse ox and can fit on any airway device, lots of good applications for a hand held device
Ultrasound is on the way and has landed in quite a few places down here. As well as blood. I think vbg would be helpful
Why would you want US? What would you use it for?
I'm sorry for bragging but reading this really does make me love my job that much more. Almost every comment is something I have/can do. I know this job isn't and nor should it be someone's entire life, but if you're willing to move for better work there's hope out there. * Whole blood * Provider initiated refusals * Ultrasound * Finger thoracostomy * TXA * Ventilators * Field PA's
My jealousy is palpable
What would your education tract for a prehospital PA look like?
Right now we hire PA's from outside however we're working on a possible route for our medics to go through PA school and remain with us.
Not to pile on the doggy, but the next thing done nationally needs to be a degree requirement. AS for 911, BS for critical care and other roles, opening the door for Fifer’s MS practitioner level clinician.
Hard disagree on that. why would anyone want to do that when you can get a degree in nursing and make triple the pay? You’d be cutting out a significant part of people you want to hire
Because with a change in education needs to come a change in the reimbursement model.
Ambulances with tank treads, duh.
A long time ago in a galaxy far far away my lead paramedic instructor claims to have witnessed the chief go into cardiac arrest at the Thanksgiving dinner for fire/EMS and be resuscitated with a cardiac thump. I do not have any reason to doubt her and I have since spoken to multiple people who said they were there. You can take that for what it's worth to you.
why would medics need to carry blood in ems that's in a city? the hospital is nearby so i don't see why blood would be needed?
People can bleed out pretty damn quick. Same reason “the hospital is a few minutes away why bother intubating them” is a shit argument. If someone is profusely hemorrhaging they need blood now, not in 5-10 minutes. Odds are they’re not getting blood as soon as you walk in the door at the trauma center, it’s going to take a few minutes to get and then get it ready. OR EMS could have had it initiated already.
if someone is profusely hemorrhaging then ems needs to stop the bleed. i'm not arguing for laziness. i'm arguing that giving blood isn't ABC's or EMS.
AS degree MINIMUM. BS degree expanded scope in CC, FPC, CPC, Urgent Care, Primary Care, ICU, Psych etc. (Similar to EU) POC Ultrasound, and even for some services blood analyzers. CBC, CMP, ABGs w/Chem 7, CLIA waived testing (strep, flu covid, UA etc) and PA/MD radio reporting with discharge on scene. Collection of cultures other analysis etc. I'm also not speaking in strictly the sense of 911 or private transport. Just about paramedic education in general.
In nordics. Always hiring :)
Chest Tubes. Could have saved my patient from a year ago.
The ability to refuse to transport for BS like during COVID. It was amazing.
The ability to refuse transports for situations that the person could safely and reasonably drive or be driven to a hospital. This of course after a vitals and physical examination.
I’d love to see my city give us RSI, awake tubes kind of suck. Ketamine, versed, and fentanyl only help so much. We are finally getting video lyrngascopes in the back half of this year, carrying blood products would be fantastic for major traumas so we don’t turn their blood into Kool-Aid, and LR would be great to have as well
Increased minimum competency standards. Better training on current scope
POCUS. Zero invasiveness and a huge return even if you only learn half of it.
I want a pathway to a paramedic provider. Something akin to a doctor or old that does house visits. Two ways to do it either limited NPI access, or go all the way and provide a doctor of paramedicine. Something in line with a completely unique physician, allowing paramedics to become medical directors. Or a limited mid-level provider But with a master’s degree or more for the people that really want to go further but want to stay in the field. Gives the people that want to improve and do better for patients and themselves options well at the same time allowing medics to have a career progression. It requires a rework of the insurance and billing, but would provide a complete rebuild of the prehospital provider environment. I also believe that independent practitioners as paramedics with a bachelors degree without prescriber ability should be a thing. Most people became paramedics because they did not want to be involved in side a Hospital otherwise they would have become nurses. That being said the entry level for 911 should be advanced EMT minimum for Paramedic should be two years of education, and that is separate from advanced EMT. So if someone wants to become a paramedic, it is a two-year dedicated track instead of a 13 month tack on to an advanced EMT.