How Can Paramedics be Involved Efficiently in Medical Care at Emergency Hospital Units?

TABLE OF CONTENTS

I. Introduction.

II. The scope of Paramedic Science in the USA and Canada.

III. Provincial variations on the National Occupational Competency Profile.

IV. Special types of Paramedics in the USA..
A. Critical care paramedic.
B. Tactical paramedic.
C. Occupational health paramedic.
D. Community paramedic.
E. Incident response paramedic.
F. Paramedic specialist
G. Infant transport team paramedic.

V. Laws for Paramedics in the UK.

VI. The history and structure of ambulance care in Hungary.
A. Institutional structure.
B. Ambulance station network.

VII. Act 18/2016 Hungarian Competency Act of Health Care Workers.
A. About the Act
B. General skills.
a. Knowledge
b. Abilities
c. Attitude
d. Autonomy and Responsibility
C. Common Competencies in Nursing and Patient Treating Professionals (7.1.1.)
D. Special skills and knowledge of Paramedics.

VIII. Charts and Other Characteristics.

IX. Conclusions.

I. Introduction

The purpose of this short study, does not matter what we call it now, is to highlight the legal possibilities of employing paramedics off-board, which means, we would like to focus on the possible options to involve them into medical care at emergency hospital units. It is obvious that we lack medical doctors, nurses and other high trained staff not only in hospital wards, but also in pre-hospital emergency care. To overlap this lack and hiatus, it was several times noted in Hungary that as for competency reasons, the closest medical staff to be involved in emergency medical treatments is the paramedics. We have been dealing with medical law for more than a decade, and have been on board as paramedics (EMTs) for more than two decades now. The accurate scopes of Paramedics, competency and other conditions vary differently in the World, therefore there is not a consequent and primarily accepted competency. However, serving the streets and responding to dispatches is pretty much similar in all over the World, therefore, the main streams are almost totally related.

Throughout this document we will see the scopes and competencies as well as the education strategies of paramedic trainings in Canada, the USA and within the European Union.

II The scope of Paramedic Science in the USA and Canada

A paramedic is a healthcare professional, providing pre-hospital assessment and medical care to people with acute illnesses or injuries. In Canada and the USA, the title paramedic generally refers to those who work on land ambulances or air ambulances providing paramedic services. More and more paramedics in the USA and Canada are increasingly being utilized in emergency rooms by providing patient care in collaboration with physicians, physician assistants, nurse practitioners, registered nurses, registered practical nurses and registered respiratory therapists. Increasingly in Canada, paramedics are actively pursuing self-regulation.¹

On the other hand, the Advanced Paramedic in Ireland, for instance, is principally engaged in responding to patients who access the 999/112 service for emergency medical assistance and can provide advanced life support. This includes the skills listed for Paramedic and the use of an endotracheal tube, intravenous cannulation, manual defibrillation, thrombolysis, needle thoracocentesis, needle cricothyrotomy and urinary catheterization.² Paramedic education, or the study of paramedicine in Canada or in the States, is an intensive academic program of formal theory and clinical experience which varies from province to province. For example, the primary care paramedic program may be three months in class with 12 days on the ambulance for precepting, or a two year diploma or four year degree in primary care paramedicine in other universities. Training as an advanced care paramedic requires that the student be first registered as a primary care paramedic. Eligibility for this training varies from immediate entry following a registration to a mandatory period of experience working as a paramedic usually one to three years. The length of time required to complete paramedic training also varies between provinces, and it is generally inversely related to the length of time required to have completed the prerequisite training.³ Shorter (around one year) programs build upon the education already learned in a two-year paramedic training program, while longer (typically up to two years) college programs typically cater to paramedics who graduated from shorter programs

Therefore, while there is continual debate on the merits of longer or shorter paramedic programs (often centered around teaching philosophy), in common, ACPs across Canada and the USA will generally have completed approximately three years of intensive formal education, inclusive of didactic study and clinical placements. There are ASS (Associate Bachelor) degrees of advanced EMT cares, Bachelor degrees (BSc), and also Masters degrees in APN (Advanced Practice Nurse).

There are two Bachelor of Health Science in paramedicine degrees currently available in Canada and in the USA, are becoming the standard of paramedic education as the profession progresses at the Primary Care Paramedic entry level. This would be comparable to when nursing moved from the college based program to the collaborative or university based program in Canada. These programs are often offered through partnerships between Canadian universities and colleges, blending vocational training with higher education. (eg. EMT-Advanced and Paramedic BSc).

Paramedic degrees were probably first created overseas and in the UK, therefore in the European Community, this education was for long ignored. After the Second World War it came into a primary focus, since there was a very severe lack of medical doctors, and also the view and aspect of primary medical treatment had changed. It became absolutely obvious that no medical doctor degree would be needed for primary medical cares, hence a good trained nurse or a paramedic (at that time ambulance nurse) could intervene if it was needed.⁴

The accreditation of paramedic educational programs in Canada also varies from province to province. The Canadian Medical Association's Committee on Conjoint Accreditation offers the most comprehensive and best known system of national accreditation.[5] Their accreditation model is an independent body, and draws from The "National Occupational Competency Profile" as the benchmark document that details the knowledge, skills and abilities outcomes that must be possessed by practitioners of each respective level of paramedic practice.

In Canada the scope of practice of paramedics is described by the National Occupational Competency Profile (NOCP) for Paramedics document developed by the Paramedic Association of Canada with financial support from the Government of Canada. The NOCP outlines four provider levels: Emergency Medical Responder (EMR), Primary Care Paramedic (PCP), Advanced Care Paramedic (ACP), and Critical Care Paramedic (CCP)⁵

III Provincial variations on the National Occupational Competency Profile

Of considerable relevance to understanding the nature of Canadian paramedic practice, the reader must appreciate the considerable degree of inter-provincial variation. Although a national consensus (by way of the National Occupational Competency Profile) identifies certain knowledge, skills, and abilities as being most synonymous with a given level of paramedic practice, each province retains ultimate authority in legislating the actual administration and delivery of emergency medical services within its own borders. For this reason, any discussion of paramedic practice in Canada is necessarily broad, and general. Specific regulatory frameworks and questions related to paramedic practice can only definitively be answered by consulting relevant provincial legislation, although provincial paramedic associations may often offer a simpler overview of this topic when it is restricted to a province-by-province basis.

Regulatory frameworks vary from province to province, and include direct government regulation (such as Ontario's method of credentialing its practitioners with the title of A-EMCA, or Advanced Emergency Medical Care Attendant) to professional self-regulating bodies, such as the Alberta College of Paramedics. Though the title of paramedic is a generic description of a category of practitioners, provincial variability in regulatory methods accounts for ongoing differences in actual titles that are ascribed to different levels of practitioners. For example, the province of British Columbia is the only province that uses the title "Infant Transport Team Paramedic", or 'ITT Paramedic' for PARAMEDICs who have received additional critical care training for pediatric, neonatal, and high risk obstetric emergencies.[8] All provinces, however, have moved to standard titles, or have at least recognized the NOCP document as a benchmark document to permit inter-provincial labor mobility of practitioners, regardless of how titles are specifically regulated within their own provincial systems.⁶

IV Special types of Paramedics in the USA

Training for specialization as a paramedic is most often provided by employers who select paramedics that have gone through an internal competition. There are very few specialization education programs open to the public currently. An exception being STARS Critical Care and Transport Medicine Academy, offered jointly by STARS Air Ambulance and the University of Calgary. Most specializations require the applicant to already be an experienced advanced care paramedic.

A. Critical care paramedic

Critical care paramedics' (CCP) expertise focus on critical and ICU level care, stabilizing and transporting patients from smaller hospitals with less available resources to tertiary care, and regional medical programs in to other hospitals that can provide a higher level of care. CCPs generally work with an ACP, registered nurse, physician, or another CCP. Sometimes ad hoc teams, with multiple practitioners (RTs, emergency physicians, surgeons, etc.) are assembled for certain patients.

CCPs are able to provide all of the care that PARAMEDICs and ACPs provide. In addition to this they are trained for other skills such as medication infusion pumps, mechanical ventilation and arterial line monitoring. CCPs often work in fixed and rotary wing aircraft when the weather permits and staff are available, but systems such as the Toronto EMS Critical Care Transport Program work in land ambulances. ORNGE Transport operates both land and aircraft in Ontario. In British Columbia, CCP's work primarily in aircraft with a dedicated Critical Care Transport crew in several cities for long-distance/high acuity transfers and as regular CCP street crews who may do major trauma calls or, performs medevacs, when necessary. Across the prairies, rotary wing aircraft is used to reach many in isolated communities and traumatic situations for faster response time than by ground ambulance. In Saskatchewan they also use fixed wing air ambulances. The service, called Lifeguard, can respond a greater distance and to more northern communities than STARS. Sask air ambulance service was the first non-military air ambulance service in the world.[14] These air ambulances are crewed by Flight Nurses and CCPs.

B. Tactical paramedic

Tactical paramedics are specialized paramedics who undergo additional training to allow them to perform their usual task in a high risk and dangerous scenario. Some are trained to handle weapons, repel from buildings and other skills needed to work alongside tactical police units. These paramedics are required to wear protective gear but are unarmed.

C. Occupational health paramedic

Occupational health paramedics work closely with occupational physicians and nurses to help with pre-employment screening, medical surveillance programs and clinical testing for companies.

D. Community paramedic

The newest level/role for paramedics in Canada and in the USA, community paramedics work in clinics, hospitals, and in patient's homes. They provide immediate or scheduled primary, urgent and specialized healthcare to vulnerable patient populations by collaborating with other healthcare providers, conducting assessments, treating, and doing/ordering tests.⁷ Diagnostics provided by Community Paramedics: Specimen collection (blood, urine, swabs), 12/15 lead ECGs, vital signs (temperature, blood glucose, SPO2, side stream CO2, BP), and facilitate transports for diagnostic imaging. Treatments provided by Community Paramedics: CVC IV rehydration, blood transfusions, urinary catheterization, wound closure care (tissue adhesive, sutures, dressings), oxygen and nebulizer therapy, IV/SQ/IM/PO/PORT/PICC medication administration (including IV antibiotics), and coordination of community services.

E.Incident response paramedic

A type of specialization in Al Metro areas, IRPs receive intensive training, including toxicology, hazmat chemistry, National Fire Protection Association hazmat awareness and operations certifications, as well as three weeks of CBRNE training, antidote, medical countermeasures, MCI and, protective equipment training.

For day-to-day operations, IRPs respond to hazmat- and toxicology-related incidents. They carry a wider range of medications than advanced care paramedics and more protective equipment, allowing them to better treat poisonings/overdoses and work closely with firefighters and hazmat technicians.

F. Paramedic specialist

ACPs and CCPs in British Columbia that provide on-scene technical support for high-risk situations, mass and complex patient events as well as telephone support to paramedics and patients. Typically work in solo response vehicles in Metro areas or in dispatch centres.

G. Infant transport team paramedic

Only a designation in British Columbia, ITT paramedics are specially trained ALS paramedics who undergo extra training to provide emergency medical care for BC pediatric, neo-natal and high-risk obstetrics patients while en route to specialized care units in hospitals throughout British Columbia, the Yukon Territories, other parts of Canada and the United States as required.⁸

V. Laws for Paramedics in the UK

The legal system in place within the UK can be broadly divided into two main branches: criminal law and civil law. Table 1.1 details the differences and similarities between these two areas. Paramedics are subject to the same legislation as any other individual in the UK, and are specifically named in practice notes for particular legislation such as the Mental Capacity Act 2005. In practice, the majority of legislation that impacts on the day-to-day work of the paramedic is dealt with by the paramedic’s employing authority. Health and safety, data protection, drugs regulation, medical equipment safety, and human rights are all areas that are legislated and put in place by employers. Paramedics as individuals are more likely to fall foul of the civil side of the law if they either lack competence or engage in behavior which could be considered as misconduct. This will be discussed under the heading of professional regulation. A third branch of the legal system is that of the coroner’s inquest. Threats of ‘explain it to the coroner’ have historically been used to encourage student paramedics to do the right thing when treating patients and when completing records, often portraying the coroner as someone to be feared. This is simply not the case. The role of the coroner in relation to deceased individuals is to establish facts. There are four main facts that the coroner must establish: the identity of the deceased; the place of death; the time of death; how the deceased came by their death. Coroners are usually lawyers with specialist training, with only about 25 per cent being medical doctors with a legal qualification. The coroner’s inquest follows an inquisitorial process which aims only to establish the facts, as opposed to criminal and civil cases which follow an adversarial process with one side trying to prove that their case is more just than their opponents. Paramedics may be called upon to provide written witness statements of fact to the coroner and any patient report records that they have completed may also be subjected to scrutiny. Moreover, in some cases where further clarification is needed, the paramedic may be required to give evidence at a coroner’s inquest. Once the paramedic has answered any of the coroner’s questions, the coroner may invite any interested parties to question the paramedic. This means that relatives of the deceased, or their representatives, may ask the paramedic questions. This can be a difficult and uncomfortable experience for the paramedic concerned, but it often goes a long way to giving bereaved relatives a greater understanding of what happened to their loved one. In order to make such experiences as pain free as possible, it is vital that the paramedic thoroughly documents all details for all the calls that they attend.⁹

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¹ Talabér j., , Kompetenciák a sürgősségi betegellátásban , Előadás: Szeged, MRT Kongresszus, 2007. szeptember 15.

² http://ec.europa.eu/growth/tools-databases/regprof/index.cfm?action=regprof id_regprof=26427

³ Göbl G. Oxiológia, Medicina, Budapest, 2006.

⁴ Talabér j., "Mentő protokoll? - eljárásrend szemle jogász szemmel"., MSOTKE Konferencia, Budapest, 2015. november 12-15.

⁵https://en.wikipedia.org/wiki/Paramedics_in_the_United_States

⁶ "Nationwide Directory of Paramedic Schools". Retrieved 2008-11-07.

⁷ "National EMS Scope of Practice" (PDF). Retrieved 2012-11-11.

⁸ V.Clarke, G.Harris, S. Cowland (eds), Ethics and Laws For Paramedics, London, 2009.

⁹ https://www.mheducation.co.uk/openup/chapters/9780335243877.pdf