Several trade journals have asked fire and EMS professionals to comment on the National EMS Scope of Practice document. Thousands have written the National Highway Traffic Safety Administration and the principal investigator on this project. The document triggered enough concern that CNN ran a story about how this document would hinder the ability of rural providers to maintain their certification. The efforts are continuing to standardize the scope of practice and develop the medical practice of pre-hospital providers as the project moves into version 2.0. The final document is scheduled to be completed in September.

The Scope of Practice document was put together through a consensus-building process with both the International Association of Fire Chiefs and the International Association of Fire Fighters. The first version of the document was a rough draft and blueprint for what skills and abilities can be practiced and at what certification levels. Some major changes in certification levels have been adjusted from the original proposal by NHTSA. Many felt that the original document would have a significant impact on the level of medicine practiced in the field by fire-based EMS.

The scope of practice model is an essential component of EMS Agenda for the Future, which attempts to create a uniform system of EMS licensing. In 1998 the Pew Health Professions Commission Task Force on Health Care Work Force emphasized the need for the states to implement a nationally uniform scope of practice. The goal is to have national licensure or certification for the entire country to help the EMS system evolve into a more community-based health-management system instead of just an EMS system.

Why does the need for licensure now outweigh the need for certification? Professions that employ licensure generally have more stringent standards for those practicing in the field. Licensure systems allow for an improved system of handling allegations of licensee incompetence. Most importantly licensure, when linked to standardization of the scope of practice and common educational standards, allows for reciprocity. Licensure also offers autonomy, which may allow EMS workers to enter the clinic, office or emergency room and provide a career path for more senior EMS workers.

Certification is considered a series of standards adopted by an agency that are based on competency. In 1996 NHTSA identified at least 44 different levels of EMS providers. Under the proposed scope of practice document there will be four proposed levels of certification: emergency medical responder, emergency medical technician, paramedic and advanced-practice paramedic. The levels between paramedic and EMT were eliminated in the original draft, but have been returned in version 2.0. The skills and abilities for some of the levels are being reworked to have the minimum-entry requirements for those skills delineated. A version of an IV technician may reemerge to accommodate rural issues.

The advanced-practice paramedic turned out to be a very controversial topic and has been left out of further discussion for now. This level of skill needs validation through evidence-based practice; the airway skills proposed for the advanced-practice paramedic include surgical cricothyrotomy, ventilators and paralytics medications, and recent medical studies are questioning the effectiveness of intubations in the field.

A significant increase in pharmacological intervention skills is proposed, with advanced-practice paramedics having the ability to administer blood, place central lines, monitor arterial lines, and administer local anesthesia and tetanus. Wound closure is added as an emergency skill, yet the definition doesn't specify sutures or glue and what area of the body. In many rural locations and in home health scenarios, this skill could save a patient a trip to the hospital and produce substantial savings for the health care system.

The coursework needed for each of the levels will change, as increased EMT hours and the need for an intermediate level remain hot topics. In 1998, changes to the paramedic curriculum recommendations included college English, math, and anatomy and physiology prior to entering paramedic training. A single course for the two lower levels of proposed licensure is what is in place as an educational standard. The paramedic-level licensure would require completion of an accredited paramedic program with either a certificate or an associate's degree. The paramedic level will continue to require a substantial amount of independent decision-making, and the appetite is still there for both certificate and degree programs. There will need to be more physician supervision of paramedics and EMTs in the future.

These educational requirements will affect the fire service. This level of service may provide an opportunity for private ambulance to establish a niche in a community. Operation of critical-care transport units is dominated by private ambulance, which can advance and be more responsive to market factors. Private ambulance is not constrained by traditional hiring policies that place barriers between highly educated outside prospects. The educational requirements also will be an obstacle for fire-based EMS and may place educational demands in conflict with union contracts.

The real-world politics are almost certain to make changes in the scope of practice difficult. Many of the skills for the proposed advanced-practice paramedic are encroaching on the turf of other health care professionals. To allow the advanced-practice paramedic to practice in the field, most states and regulating agencies will have to modify their medical practice acts. Legislation will be open to intense lobbying efforts from nursing, respiratory therapy and other allied-health professions. This will be a battle in which EMS can't maintain or conduct effective lobbying efforts. EMS does not speak with one voice and does not have the organizational and financial support of other allied-health professions.

However, advancing the medical practice of paramedics may be justified for two important strategic reasons. First, the advanced-practice paramedic skills would enable a paramedic to function in a clinic or, more importantly, in a casualty-collection area during a disaster. According to some studies, more than a third of first responders would be affected in a CBRN attack. Remaining emergency responders would be forced into longer shifts. Outside resources would need to be brought in but with the current nursing shortage might not be available.

Second, the aging of America is about to turn the health care system upside down. By 2020, the shortage of physicians is projected to be 200,000 below the number needed to take care of Americans over the age of 65. This will place a larger demand on the allied-health professions.

Change is hard, and the anticipated increase in levels of care to come from this document may seem exclusionary and will require long-term implementation, including new legislation. What may be more appropriate is to build a bridge course that will take an experienced EMS provider from paramedic to physician assistant. This would not require the medical practice acts of the respective states be opened or modified. This could present an opportunity for a partnership with the physician assistant community and not involve a legislative fight between interest groups defensive about issues related to turf. Attractive salaries and accredited institutions are currently in place to service this need.

Changes won't need to be made to the health care or Medicare system to allow for reimbursement of the skills or services that are proposed under the advanced-practice paramedic. In a profession that has a limited amount of evidence-based practice to justify existing ALS skills, it seems more logical to transition EMS providers to the physician assistant level, which has an established track record and economic justification. Physician assistants are represented by professional associations and have well-established licensure procedures. Adding another level to EMS ranks may not be the answer.

The deadline for comments on the second draft of this document is in June. The nation's EMS providers need to trust the principal investigators to serve the people and do what is best for the patient. The comments and continued feedback will continue to build consensus by those who do the work. It's important that you as an EMS manager submit your thoughts and ideas to principal investigators and the Department of Transportation as they continue to advance EMS and respond to the changing demographics of our population.

Bruce Evans is the fire science program coordinator at the Community College of Southern Nevada as well as an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. A captain at the Henderson (Nev.) Fire Department, he has an associate's degree in fire management and a master's degree in public administration.

The National Scope of Practice document can be found at www.nhtsa.dot.gov/people/injury/ems/EdAgenda/final/index.html@