Adolph H. Giesecke, M.D.
George W. Hatch, Jr., Ed.D, L.P., EMT-P

he emergency medical service as we now know it began in the early 1960s because of the innovative genius of two anesthesiologists working independently: Peter Safar, M.D., and Eugene Nagel, M.D.^{1, 2} They recognized that if the newly discovered technique of external cardiopulmonary resuscitation (CPR) was to benefit the public outside of the operating room, then they must train paramedics who would be widely distributed in society and create systems for emergency care in the hospitals to receive the victims who were resuscitated in the field. Their inspiration has grown into the highly integrated, highly successful system that currently benefits our public. All that we have to do is to dial “9-1-1,” and this incredible public service comes to our aid, starting with a well-trained paramedic.

Figure 1. Paramedic students practice CPR skills in the laboratory of the training program at Southwestern Medical School in Texas. Photo by Kenny Navarro.

Paramedics are an essential component in the prehospital care of the traumatized or acutely ill patient, and they possess the knowledge, skills and behaviors consistent with performance of that duty. Specifically, they can evaluate and form a presumptive diagnosis, measure vital signs, take and interpret a 12-lead electrocardiogram and transmit this information to a base station, called a “BIOTEL.” At the base station, a medical doctor, usually a specialist in emergency medicine, reviews the information and prescribes a treatment from the list of competencies in the paramedic’s scope of practice. These include starting an I.V., giving drugs by bolus or infusion and managing the airway (including bag and mask ventilation, insertion of oral and nasal airways, endotracheal intubation and use of rescue devises such as Combitube^® or laryngeal mask airway [LMA]). They can perform CPR, defibrillations, insert chest tubes, stabilize fractures, stop bleeding and deliver babies. In addition, they can do these things in a roadside ditch near an overturned car, in a burning building or in other hazardous situations.

Paramedics receive their training in one of approximately 600 programs in the United States. The training follows a curriculum prescribed by the National Highway Transportation Safety Administration (NHTSA). The curriculum can be viewed on the NHTSA Web site www.nhtsa.gov/people/injury/ems/EMT-P. The curriculum requires approximately 900 clock hours to complete and consists of classroom lectures, skills laboratory, clinical hospital preceptorships and field internship experience. The graduating student receives a certificate, an associate’s degree (A.A.S.) or a baccalaureate (B.S.) degree depending on the program. Programs based in fire services, hospitals or ambulance services usually offer the certificate; those based in community colleges usually offer the A.A.S.; and those in universities or medical schools usually offer the B.S.

More than 250 of the programs are nationally accredited by the Committee on Accreditation of EMS Programs/Commission on Accreditation of Allied Health Education Programs (CoAEMSP/CAAHEP) www.coaemsp.org/www.caahep.org. ASA has two liaison representatives on the CoAEMSP Board of Directors: William H. Montgomery, M.D., of Honolulu, Hawaii, and Adolph H. Giesecke, M.D., of Dallas, Texas. National accreditation is required in 14 states, which are identified in Table 1. Graduates of nationally accredited programs are eligible to take the National Registry of EMTs (NREMT) examination. Those paramedics with the designation NREMT-P have been trained and proven by examination to perform to national standards. The level of standardization of educational programs in the remaining 36 states, where approval is provided by state health departments, is as varied as their state flowers. Many programs are excellent — many require a lot of work to achieve the national standard. The need for a standardized approach to the evaluation of educational programs in EMS became painfully evident following September 11, 2001, and Hurricane Katrina. The paramedic of the future must be able to function in any state in the nation where a mass casualty event occurs. Universal accreditation of EMS educational programs within the United States will help to meet that need by ensuring that all programs meet rigorous requirements.

Universal Accreditation
In 2000, the EMS Educational Agenda for the Future: A Systems Approach detailed the steps required to bring training programs and graduates into compliance with national guidelines for the profession.³ At the time, the document was wide-reaching in its scope. Much of the agenda has been completed; however, the promise of universal accreditation is unrealized. In fact, extensive negotiations are needed to encourage the remaining 36 states to require accreditation.

The case for national standardization of EMS education was advanced by the release of the Institute of Medicine’s report Future of Emergency Care: Emergency Medical Services at the Crossroads (2006),” which called for universal accreditation for all paramedic education in the nation.⁴ In addition, the NREMT Board of Directors is considering the far-reaching requirement that all candidates for the national certification examination must come from CoAEMSP-accredited programs by 2013. The EMS community will likely be greatly engaged in extensive debate on this topic. The new requirement should be viewed as an opportunity to improve the profession of EMS providers, but opponents will see it as an attempt to limit their ability to offer their own version of high-quality paramedic education.

The CoAEMSP is prepared to accept a large number of applications from uncertified programs and will be positioned to move ahead with universal accreditation efficiently and expeditiously without compromising quality. The whole discussion seems strange to medical specialists whose training programs have required national accreditation for decades.

Why Should Anesthesiologists Care?
Many reasons come to mind. First, we may someday need the services of a paramedic. We would like advanced reassurance that the paramedic who responds to our personal emergency is trained to a national standard. Second, anesthesiologists conceived the EMS; it is our brainchild, and even though it has evolved away from us, we should maintain an interest in its welfare. Third, because many of the skills required by a paramedic reside in the domain of anesthesiologists, and we are best-suited to teach and refresh those skills. We refer to the skills required for airway management, such as good mask fit; good head position, especially in obese patients; use of oral and nasal airways; use of the LMA and Combitube and, of course, endotracheal intubation. Anesthesiologists can and should provide supervised experience in these skills in the operating room, and that experience is positively correlated with improved success in airway management in the field.

My coauthor George Hatch relates the following anecdote:

“My own experience was one in which a noted anesthesiologist in our community was not in favor of paramedics utilizing endotracheal intubation in our early days of practice in the late 1970 and 1980s. He was concerned that our abilities were not where they needed to be, and I would agree with that assessment. We received additional work at another hospital to hone those valuable skills, which paid off in the future. Surprisingly enough, we were called to a cardiac arrest in the neighborhood where he lived and successfully resuscitated a neighbor in the front yard of the home. The anesthesiologist subsequently became a huge supporter for our program and our students.”

George was able to win one over. The situation across the country, however, is at crisis level. Anesthesiologists and nurse anesthetists are progressively withdrawing and refusing to offer training to paramedic students.⁵ The reasons given are fear of liability, sharply reduced use of endotracheal intubation in anesthesia practice, lack of informed consent and fear of Health Insurance Portability and Accountability Act violation. Nobody that we know is willing to say that additional mannequin practice will substitute for supervised experience with live humans in the operating room. We feel strongly that if anesthesiologists cannot overcome these reasons to oppose training in airway management for paramedics, then they must help to create alternatives to the skills involved and help to train paramedics in the proper use of the alternatives. To complicate this crisis, evidence is building that prehospital endotracheal intubation does not offer the benefits that we once believed it would. In fact some studies suggest that prehospital intubation increases morbidity and mortality, especially in children.⁶ Other studies suggest that the LMA, Combitube or Laryngeal Tube^® are suitable alternatives.⁷

This crisis in the training of paramedics in airway management will not be solved easily. The solution will require a consensus of decision-makers among paramedics, emergency medicine physicians, surgeons, pediatricians, cardiologists and anesthesiologists, all of whom share a commitment to high-quality prehospital care. We urge all readers of this article to participate in the operating room training of paramedics and to help establish the consensus regarding the type of airway management that should be practiced by paramedics.


References:
1. Safar PJ. On the history of emergency medical services. Bull Anesth History. 2001; 19:1-11.
2. Nagel E. History of Emergency Medicine: A memoir. Bull Anesth History. 2001; 19:1-11.
3. National Highway Traffic Administration, Emergency Medical Services Education Agenda For The Future: A Systems Approach; 2000: 28-30.
4. Institute of Medicine of the National Academies. Future of Emergency Care, Emergency Medical Services at the Crossroads, National Academies Press, Washington, DC; 2006: 9,119-126.
5. Giesecke AH, Montgomery WH. The role of the anesthesiologists in paramedic training. ASA Newsl. 2005; 69(11):5-6,22.
6. Gausche M, Lewis RJ, Stratton, SJ, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome. JAMA. 2000; 283:783-790.
7. Agro F, Frass M, Benumof JL, Krafft P. Current status of the Combitube: A review of the literature. J Clin Anesthesia. 2002; 14:307- 314.

Adolph H. Giesecke, M.D., is Emeritus Professor, Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.

George W. Hatch, Jr., Ed.D., L.P., EMT-P, is Executive Director, Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions, Houston, Texas.