• #JessInTheUS – New York

    by Jess Morton. Last modified: 24/07/15

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    With thanks to our friends at Zoll and Ferno.

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    New York was a place I had long wanted to visit as a tourist. I originally scheduled in a detour to NYC enroute to smaccUS to fulfill my dream of seeing my two favourite musicals on Broadway.

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    However, it soon became evident that I could also utilise my time to create a learning opportunity like none other. It was solely thanks to the generous support of Zoll EMS and Ferno Australia that I was able to embark on this journey to New York.

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    I was fortunate enough to be able to book in a ride-along with the Fire Department of New York (FDNY) during my week in NYC. It is apparently policy that unless you are an on-road working paramedic you can only ride on with the EMTs’ rather than the ALS paramedic crews, so I wasn’t able to observe medics of my own scope of practice back home. However, it still provided an opportunity to learn a lot. During the first few days of my time in New York, I had observed EMTs around town picking up patients. It hadn’t gone unnoticed that they appeared to arrive on scene and depart quite quickly. I recalled a comparative essay I wrote in my first year at university about the difference between the US “scoop and run” vs the Australian more “stay and play” system.

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    Up until walking onto station, I had little insight into the scope of practice or training involved in working as either a BLS or an ALS medic in the US. I was beyond excited to go out with the FDNY and was very appreciative of their hospitality. Due to policy, I am unable to share photos (or take any) or elaborate on any of the cases I attended with them.
    The FDNY mostly operates under a two-tier system, Emergency Medical technicians (EMTs) and ALS paramedics. The EMTs may complete the required 180 hours of training in as little as 3-5 months. The EMT role works primarily as a first responder and transportation. They have the skill to initiate spinal immobilisation, assess vitals and defibrillate using an AED. Their scope and skill level is quite similar to that of the St John ambulance volunteer first responders that operate in Australia. However, they are also able to insert LMA and guedel airways.

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    It was eye opening to observe clinicians of this level responding to emergency calls. The EMT has the ability to request paramedic backup where it is deemed that clinical support above their scope requires it. But it did interest me if the condensed EMT training model provides enough education to give EMTs the clinical knowledge to always know when they need back up.
    For example; in the case of the septic patient, does the EMT-basic course provide a comprehensive enough background for the EMT to be able to differentiate between a patient who is febrile and generally unwell and the patient who is septic? The New York EMT scope of practice does not allow for the initiation of IV fluids or antibiotics (which are allowed in some prehospital services across the world).
    Whereas, an advanced care paramedic (ACP) in Australia would assess the patient, if the clinical presentation pointed towards sepsis, they would complete their assessment with vitals, a blood sugar, possibly a POC lactate, 12-lead ECG and a comprehensive history. The paramedic could commence IV fluids, oxygen and pre-notify the receiving facility of a CERS patient.

    It was surprising to learn that New York EMTs’ do not carry, nor can they administer any drugs except oxygen. I was able to find some information on the New York EMT assessment criteria here: https://www.health.ny.gov/professionals/ems/basic.htm
    You will see that EMTs are expected like others to assess mechanism of injury and scrupulously consider spinal cord injury by checking dermatomes. The scope of practice appears to be narrower than in other US states, which does allow the EMT to administer certain drugs such as aspirin and naloxone under medical guidance.

    A table of the scope of practice in regards to drug therapy for the National Registry of Emergency Medical Technicians (NREMT) can be found here

    Download (PDF, 1016KB)

    This can be compared to the Queensland ambulance (Australia) drug therapy protocols https://ambulance.qld.gov.au/dtprotocols.html
    As previously mentioned, most Australian paramedic students complete a 3-year undergraduate bachelor degree now before they can apply for a graduate paramedic position. Each university semester is approximately 12-14 weeks where both the curriculum and assessments are intense. I began my university degree at Central QLD uni, but transferred to Edith Cowan University after 2 years for personal reasons. I have attached the course structure from both of these uni’s to get a better appreciation of the extensive science background we study.

    Download (DOCX, 127KB)

    Download (DOCX, 125KB)

    On Day 4, I was so fortunate to meet with Professor Scott Phelps from New York, his friend and paramedic educator Gene as well as one of his ALS students, Carlos for lunch. I also took the opportunity to rope in my good friend and Australian rural intensive care and extended care paramedic, Matt Simpson. ( We needed to even out the U.S. to Aussie ratio) It was an incredibly insightful discussion over lunch as the five of us compared our own training, scope of practice, models of care, make of ambulance and the all important “war stories”. I had followed Scots contribution to #FOAMems on twitter for quite a while (@medicscience) and his extensive knowledge of paramedic education, the prehospital systems around the world as well as his own thoughts on how improvements could be made to make some of these services more efficient was almost daunting.

    It was a great privilege to be able to sit next to Carlos, a fellow student from the other side of the world. Carlos has a rich prehospital background and has committed to completing his paramedic training. From the brief time I spent with him, I know that he will be able to contribute much to the lives and care of New Yorkers in the future.

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    I have a greater appreciation for the dedication that students submit themselves to. The medic (BLS or ALS) training in the U.S could be similarly equated to that of the Enrolled Nurse training in Australia. Enrolled nurses have typically completed either a Certificate IV or diploma in nursing over the course of 12-24 months. They generally need to pay their fees as they go and a lot of information and expectation is condensed into that intense period. Assessments are often a combination of multiple-choice, labeling diagrams and short response answers. Upon completion of the course, graduates can apply for registration with AHPRA (Australian health practitioners regulation agency) before they can apply for a position for a hospital or health service.

    The Enrolled nurse scope of practice has rapidly expanded over the past 12 years. Depending on which jurisdiction you work under, they can administer schedule 2,3 & 4 medications, monitor and check schedule 8 drugs including ketamine infusions, PCAs and epidurals etc. Whilst they work under the direct or indirect supervision of a registered nurse, they are responsible for their own practice and competence. The intensity and rush of education and knowledge are very similar to the average U.S medic training. Whilst it isn’t a long, drawn out degree encompassing all the ethics, communication and cultural sensitivity subjects that registered nurses or Australian trained paramedics undergo, it certainly does provide a platform for a highly competent, skilled and compassionate clinician, (3 attributes which I believe are required to be good at what you do).

    There are certainly large differences between the prehospital model of care and scope of practice of New York and Australian medics. It was great to see that medics are somewhat regulated by the NREMT in the US. Paramedic Registration is still being fought for by Paramedics Australasia in Australia and New Zealand.

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    What I loved was that the same larrikin personalities were amongst the team in New York as they are back home in Aus. From the moment I stepped on station, it was evident that the same dry, witty, and somewhat deranged sense of humour of paramedics is universal. Some have said it is a coping mechanism to deal with the things we see and face.. It could also be a side effect of unique personality type that loves what we do in spite of the things we see and face.

    My limited time with NY medics was a highlight. I think my heart skipped a few beats as I stepped into that ambulance and when I first heard those infamous sirens and horn sounding. I am very grateful for that time. It not only gave me an incredible experience, but it also helped me reflect on my own patient assessment skills and consider what clinical management I would instigate according to local protocols.

    Next up I will share my experience of visiting the incredible NYSim centre at the Bellevue Hospital in New York City.

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    Jess xx

    Thankyou to Zoll EMS and Ferno Australia for their support.

    zoll

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    Jess Morton

    Jess Morton

    Student Paramedic.
    I am an Australian undergraduate Student Paramedic. I study part-time as I am also Mum to 2 beautiful boys. I am passionate about Friendship, Family & #FOAMed. I am keen to get more experienced as well as student Paramedics into the FOAM world to enable better access to education to result in better patient care. My interests include photography, thick shakes and sleeping in past 6am.

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