Getting Down to Details: EMS Education Standards Part 2

      This is the second in a series of three articles on the new National EMS Education Standards. This article will look at some of the details and differences in the education standards as compared with curricula developed in the 1990s.

FUNDAMENTAL DIFFERENCES

   Differences will be found between the education standards and existing curricula on both minor and more significant conceptual levels.

   Prior curricula were developed with significant restrictions early in the process. Early curriculum development was based on a predetermined number of hours, which placed limits on the skills and concepts presented. The current education standards were developed based on the EMS Core Content and Scope of Practice documents and recommend content based on determination of the depth and breadth of the material, and do not have a set number of hours. Course length is based on competency, not hours.

   This is also the first time all four levels were created at the same time. Previous levels were done at different times (EMT-B 1994, First Responder 1995, Paramedic 1998 and EMT-Intermediate 1999). The development as a continuum rather than separately helped to strategically differentiate the levels while implementing the scope of practice document in an effective and timely manner.

   Organization of the standards also varies significantly from the older national standard curricula. Prior curricula were defined into lessons placed specifically into modules. This created an implication that the curriculum was to be followed in the order presented. The educational standards use competencies with content elaboration and clinical behaviors/judgments as the structure of the document. The presentation itself implies less designated structure and allows more freedom in presentation.

OTHER DIFFERENCES

EMERGENCY MEDICAL RESPONDER

   A name change is the first difference between the new EMR and the old First Responder. The differences are much deeper in content and concept.

   The 1995 First Responder was capped at 40 hours in development and was designed for those peripherally involved in EMS. Although most books and courses had significantly enriched content, the curriculum itself was limited to illness and injury where a first responder could physically make a difference. This resulted in a curriculum that taught environmental emergencies and childbirth but did not contain cardiac or respiratory emergencies—very common complaints—because the first responder wasn't taught oxygen therapy and couldn't directly impact the condition.

   The Emergency Medical Responder standards use the depth and breadth concepts to guide education appropriate for someone who responds to emergencies regardless of their affiliation. Higher levels are given to critical measures such as scene size-up, airway and primary assessment, while a wider range of medical and traumatic conditions are introduced at a simple breadth and depth.

EMERGENCY MEDICAL TECHNICIAN

   The first change (and one that is welcomed by many) to the Emergency Medical Technician level is dropping "Basic." The new level is "Emergency Medical Technician."

   On the conceptual basis, this level has undergone a significant philosophical change. The 1994 EMT-B assumed the student did not need to know anything that wouldn't directly impact care. For example, the EMT didn't have to know anything about specific respiratory conditions, because at the EMT-B level, treatment for all respiratory conditions is essentially the same. The term "painful swollen deformed extremity" (instead of fracture or suspected fracture) was a rallying cry for those who believed the curriculum was too simplistic and restrictive.

   The EMT-B curriculum resulted in a chasm between the document, practice and education. Many supplemented (or "enriched" as it was known at the time) the curriculum with additional depth and breadth.

   Those who felt the curriculum was "dumbed down" will have nothing to complain about with the new education standards. In fact, many speculate the depth of the curriculum--especially the increased physiology and pathophysiology--will actually force some educators out of the classroom.

ADVANCED EMERGENCY MEDICAL TECHNICIAN

   Previously EMT-Intermediate, this new level is based on the Scope of Practice document that defines the skills included.

   The current EMT-Intermediate level is widely varied in the knowledge and skills expected throughout the country. These levels (as many as 44 different definitions of EMT-Intermediate in 40 states) range somewhere between the 1985 (more of a trauma technician concept) and 1999 EMT-Intermediate (a cut-down paramedic).

   In fact, the 1999 EMT-Intermediate curriculum was created by starting with the 1998 Paramedic National Standard Curriculum and paring it down to an intermediate level.

   The educations standards make a significant shift by creating a level that adds to the Emergency Medical Technician rather than subtracting from the paramedic level. Most notably different in the standards between advanced EMT and many practicing EMT-Intermediates is the absence of cardiac monitoring and endotracheal intubation.

   While it was hoped to create a more uniform definition of providers between EMT and paramedic, the scope of practice document does note that the skills included are a minimum. States may still add to the AEMT level--especially to meet individual needs of rural and urban EMS systems and providers.

PARAMEDIC

   The paramedic standards are considered by many to have the least change. An increasing number of accredited paramedic education programs, as well as continuous integration of current medical science into paramedic studies, has minimized the impact of the standards on paramedic practice and education.

   Perhaps the most significant change in paramedic education is the requirement that paramedic programs become accredited through CoAEMSP by 2013.

PHILOSOPHICAL CHANGES

   Perhaps causing the most stress to a profession that had previously been guided by a detailed declarative outline of course content is the general nature of the standards--namely the "between-the-lines" information that must be filled in by programs or instructors.

   The seemingly amorphous nature of the standards has many alarmed or frustrated when determining what a course should look like. In fact, several items should help guide course content. These include:

• State or regional guidance: Some states may simply adopt the education standards verbatim, while others may modify the content and/or provide more detailed guidance.
• Evidence-based emergency care: Over the past two years we have seen tourniquets increase in clinical relevance while pressure points have declined. Current scientific research must guide course content.
• Instructional guidelines: Provided to assist with interpretation, these guidelines help explain the intent of the education standards' breadth and depth. These are not designed as definitive and not intended as a detailed declarative.

DOWN TO DETAILS

   The Emergency Medical Technician and Advanced EMT levels have undergone the most significant shifts in practice and education. The remainder of this article will highlight details of changes in the EMT standards, since this level is taught most frequently and has the most significant concept and content changes.

   When comparing differences, many turn to skills as the definition of an EMS education level. The skill set for the Emergency Medical Technician is not significantly changed from the 1994 National Standard Curriculum. Some predictable additions (administration of aspirin) are accompanied by additions seemingly resurrected from the past (Venturi masks and humidification).

   The truest indication of change in the EMT standards lies in the cognitive content. Examples include the following competencies and content elaboration:

   Airway Management, Respiration and Artificial Ventilation: Physiology and pathophysiology of respiration including pulmonary ventilation, oxygenation and respiration (external, internal and cellular).

   The intent of the education standards is that a deeper understanding of the physiology and pathophysiology of respiration and ventilation is fundamental in understanding patient presentation, assessment and care for airway and respiratory conditions.

   As stated in the content elaboration, the effects of oxygen, and the lack of oxygen, will be taught to the cellular level. This will pose a challenge for many educators to present this material appropriately so students benefit from understanding and integrating this knowledge into practice.

   Many of the new devices and modalities are in the airway section, including:

• Use of oxygen humidifiers
• Use of partial rebreather masks
• Use of simple face masks
• Use of Venturi masks
• Obtaining a pulse oximetry value
• Use of automated transport ventilators
• Use of mechanical CPR devices (additional training required).

   Pathophysiology: Applies fundamental knowledge of the pathophysiology of respiration and perfusion to patient assessment and management.

   The Emergency Medical Technician level pathophysiology standard only applies to respiration, shock and perfusion (although considerable reference is made to pathophysiology in the IGs for other topics throughout the document). Yet, within this area, the anatomy, physiology and pathophysiology required (as mentioned above) are a dramatic shift from the prior EMT-B curriculum. The instructional guidelines include topics such as aerobic vs. anaerobic metabolism, ventilation/perfusion ratio and mismatch, chemoreceptors, stretch receptors and medulla rhythm centers.

   Patient Assessment: Applies scene information and patient assessment findings (scene size-up, primary and secondary assessment, patient history and reassessment) to guide emergency management.

   The patient assessment process included in the 1994 EMT-B curriculum was detailed and structured, including a scene size-up, initial assessment, focused history and physical examination, and an ongoing assessment. Not only have the terms changed, but the detailed proscriptive structure is no longer in place. Changes to patient assessment specifically include:

• Changes in terminology and procedure, which, according to the National Association of State EMS Officials, more closely correlate with other health professions.
• Scene size-up and primary (initial) assessment closely resemble the 1994 curriculum versions.
• Assessment is covered in the assessment section, as well as the medical and trauma overview sections. The concepts and techniques vary slightly between the assessment sections and medical/trauma sections. The actual assessment process may actually be a hybridization of content from both areas.
• Assessment consists of examination of "body systems," including respiratory, cardiovascular, neurological, musculoskeletal and a general anatomical head-to-toe examination. The decision of which systems to examine and when are based on the present illness and chief complaint.

   Additional changes at the EMT level include:

• Generally increased content and, in many cases, depth.
• Lifespan development and medical advances have increased content focusing on special populations, pediatrics and pregnancy complications. A geriatrics section has been added.
• Lifting and moving now included in workforce safety and wellness.
• Aspirin is included as an EMT-carried and administered medication.
• EMTs are now taught to assist with prescribed nebulized medication.
• Patient restraint is modified to meet current recommendations and practice (eliminates face-down restraint from 1994 curiculum).
• Shock content is moved from trauma and grouped with resuscitation to emphasize that shock occurs in situations other than trauma.
• Environmental emergencies are now grouped with trauma material rather than medical.
• The CDC Field Triage Decision Scheme and Brain Trauma Foundation material are references.
• The term "fracture" is used once again.

   Additional clinical requirements are also recommended. The assessment of 10 patients (real or programmed) and emergency department time are specifically mentioned:

   "Students should observe patients in the emergency department for a period of time sufficient to gain an appreciation for the continuum of care. Students must perform 10 patient assessments. These can be performed in an emergency department, ambulance, clinic, nursing home, doctor's office, etc., or on standardized patients if clinical settings are not available."

   NOTE: The comparison is between the 1994 EMT-B curriculum and the National EMS Education Standards. You may find that through evolution of EMS, changes in science, state regulations and educational materials, you may currently teach some of this material in your classes.

CONCLUSION

   While the content of the education standards has changed, even more important is that the way we do business in EMS education is clearly changing--and changing dramatically. Changes in the content and depth of material require educators and their students to have a greater foundational understanding of anatomy, physiology and pathophysiology in order to better assess and care for patients.

   No longer is the patient assessment process rote and scripted. It is based on patient presentation more closely resembling the assessment done by other healthcare providers.

   While each state will implement the new education standards differently and on a different schedule, now is the time for educators to become familiar with the new education standards in order to be prepared for the changes to come.

   To download the education standards, go to www.ems.gov.

Table 1: Recommended Hours for Training Levels

   Recommended hours for training:1

   Emergency Medical Responder: 48-60 hours

   Emergency Medical Technician: 150-190 hours

   Advanced Emergency Medical Technician: 150-250 hours

   Paramedic: 1,000-1,300 hours²

   1. Recommended hours per Education Standards. Courses may be competency-based. All hours listed include recommended didactic, lab, clinical and field.

   2. Committee on Accreditation of EMS Programs "typical range" of paramedic program hours.

Table 2: Patient Assessment Terms

Resources

NHTSA. www.ems.gov.

National Association of State EMS Officials. https://nasemsd.org/EMSEducationImplementationPlanning/Toolkit.asp#GAT071709.

• Part 1: Charting a New Course
• Part 3: Education Implementation

Daniel Limmer, AS, EMT-P, has been involved in EMS for 31 years. He is active as a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME. A passionate educator, Dan teaches basic, advanced and continuing education EMS courses throughout Maine.