Comparison of the Scope of Practice of the Army Combat Medic Specialist and Civilian National EMS Certification Levels.

INTRODUCTION: The transition of Army Combat Medic Specialists (Military Occupational Specialty Code: 68W) from military to civilian emergency medical services (EMS) is challenging, and the pathway is not clearly defined. Our objective was to evaluate the current military requirements for 68W and how they compare to the 2019 EMS National Scope of Practice Model (SoPM) for the civilian emergency medical technician (EMT) and advanced emergency medical technician (AEMT). METHODS: This was a cross-sectional evaluation of the 68W skill floor as defined by the Soldier's Manual and Trainer's Guide Healthcare Specialist and Medical Education and Demonstration of Individual Competence in comparison to the 2019 SoPM, which categorizes EMS tasks into seven skill categories. Military training documents were reviewed and extracted for specific information on military scope of practice and task-specific training requirements. Descriptive statistics were calculated. RESULTS: Army 68Ws were noted to perform all (59/59) tasks that coincide with the EMT SoPM. Further, Army 68W practiced above scope in the following skill categories: airway/ventilation (3 tasks); medication administration route (7 tasks); medical director approved medication (6 tasks); intravenous initiation maintenance fluids (4 tasks); and miscellaneous (1 task). Army 68W perform 96% (74/77) of tasks aligned with the AEMT SoPM, excluding tracheobronchial suctioning of an intubated patient, end-tidal CO2 monitoring or waveform capnography, and inhaled nitrous oxide monitoring. Additionally, the 68W scope included six tasks that were above the SoPM for AEMT; airway/ventilation (2 tasks); medication administration route (2 tasks); and medical director approved medication (2 tasks). CONCLUSIONS: The scope of practice of U.S. Army 68W Combat Medics aligns well with the civilian 2019 Scope of Practice Model for EMTs and AEMTs. Based on the comparative scope of practice analysis, transitioning from Army 68W Combat Medic to civilian AEMT would require minimal additional training. This represents a promising potential workforce to assist with EMS workforce challenges. Although aligning the scope of practice is a promising first step, future research is needed to assess the relationship of Army 68Ws training with state licensure and certification equivalency to facilitate this transition.

National examination of occupational hazards in emergency medical services.

OBJECTIVE: Emergency medical services (EMS) clinicians operate in environments that predispose them to occupational hazards. Our objective was to evaluate the frequency of occupational hazards and associations with mitigation strategies in a national dataset. METHODS: We performed a cross-sectional analysis of currently working, nationally certified civilian EMS clinicians aged 18-85 in the USA. After recertifying their National EMS Certification, respondents were invited to complete a survey with questions regarding demographics, work experience and occupational hazards. Three multivariable logistic regression models (OR, 95% CI) were used to describe associations between these hazards and demographics, work characteristics and mitigation strategies. Models were adjusted for age, sex, minority status, years of experience, EMS agency type, service type and EMS role. RESULTS: A total of 13 218 respondents met inclusion criteria (response rate=12%). A high percentage of EMS clinicians reported occupational injuries (27%), exposures (38%) and violence (64%) in the past 12 months. Odds of injury were lower with the presence of a lifting policy (0.73, 0.67-0.80), lift training (0.74, 0.67-0.81) and always using a powered stretcher (0.87, 0.78-0.97). Odds of exposure decreased with chemical, biological and nuclear exposure protection training (0.75, 0.69-0.80). Training in de-escalation techniques was associated with lower odds of experiencing violence (0.87, 0.79-0.96). CONCLUSIONS: Occupational hazards are commonly experienced among EMS clinicians. Common mitigation efforts are associated with lower odds of reporting these hazards. Mitigation strategies were not widespread and associated with lower odds of occupational hazards. These findings may present actionable items to reduce occupational hazards for EMS clinicians.

Paramedic and EMT Program Performance on Certification Examinations Varies by Program Size and Geographic Location.

Introduction: The quality of an Emergency Medical Technician (EMT) or paramedic training program is likely one factor that contributes to a candidate's success on the National Registry Cognitive Examination. However, program pass rates and their associated geographic location have not previously been evaluated. Our objective was to evaluate the performance of EMT and paramedic programs in the United States, pass rates on the National Registry Cognitive Examinations, and relationship to geography.Methods: We conducted a cross-sectional evaluation of EMT and paramedic programs' first and cumulative third attempt pass rates on the National Registry Cognitive Examination in 2015. Included were civilian EMT and paramedic programs with >5 graduates testing for certification. Descriptive statistics were calculated for program pass rates, total graduates testing, and pass rates by National Association of State EMS Officials (NASEMSO) regions.Results: We included 1,939 EMT programs (6-1,892 graduates testing/program) and 602 paramedic programs (6-689 graduates testing/program). We excluded 262 (11.9%) EMT and 51 (7.8%) paramedic programs with ≤5 graduates testing annually due to unstable estimates of program pass rates. EMT programs in the highest quartile for total number of graduates testing outperformed the lowest quartile in both first attempt (65.7% vs. 61.9%, p < 0.001) and cumulative third attempt pass rates (79.1% vs 72.7%, p < 0.001). This difference was also seen for paramedic programs on first attempt (77.3% vs. 62.5%, p < 0.001) and cumulative third attempt (91.9% vs. 76.9%, p < 0.001). EMT program pass rates for first and cumulative third attempts also varied by NASEMSO region (first: 62-68%; third: 74-78%) with the Great Lakes and West regions outperforming the other regions. Paramedic program pass rates differed by NASEMSO regions as well (first: 65-83%; third: 81-95%) with highest pass rates in the West region.Conclusions Program performance for both EMT and paramedic programs varies by total number of graduates testing and geographic location. Graduates from larger EMT and paramedic programs have higher first and cumulative third attempt pass rates compared to graduates from smaller programs. Additionally, there is variability in program pass rates across NASEMSO regions for both certification levels. Further evaluation is necessary to better understand the variability in program performance in the United States.

Demography of the National Emergency Medical Services Workforce: A Description of Those Providing Patient Care in the Prehospital Setting.

BACKGROUND: The emergency medical services (EMS) workforce is a key component of healthcare in the U.S. Characteristics of active EMS professionals who are treating patients in the prehospital setting is unclear. The purpose of this study was to describe the roles and settings in which nationally certified EMS professionals are providing patient care and to evaluate similarities and differences of the demographics and practice settings of the three major certification levels. METHODS: We conducted a cross-sectional evaluation of all nationally certified EMS professionals in the U.S. that recertified between October 1, 2017 and March 31, 2018 and October 1, 2018 and March 31, 2019. Within the recertification application, EMS professionals completed an optional demographic profile. Those who were nationally certified, functioning as a patient care provider for at least one nonmilitary EMS organization, aged 18 to 85 years, and recertified at the EMT level or higher were included. Demographic, agency and job characteristics were assessed and descriptive statistics were calculated. RESULTS: In 2017-2018, 101,363 EMS professionals recertified and 87,471 (86%) completed the profile; in 2018-2019, 106,893 EMS professionals recertified and 92,640 (87%) completed the profile. Of the 142,751 EMS professionals who met inclusion criteria, the population was primarily male (76%) and age increased by certification level. By race/ethnicity, 85% were white, 5% were Hispanic/Latino, 5% were Black/African American, 2% were American Indian/Alaskan Native, 2% were Asian and 1% were Native Hawaiian/Pacific Islander.Paramedics had the highest proportion of associate degrees (EMT:16.0%; AEMT:16.6%; paramedic:28.5%); some college experience was common for all certification levels (EMT:34.7%; AEMT:37.2%; paramedic:31.6%). Most EMS professionals reported 3-7 years of experience, were working full-time (78%) and 28% were working for 2 or more agencies. Most were working for a fire department (48%) or private agency (21%) and providing 9-1-1 service (72%). No substantial differences were observed between the two recertification cycles. CONCLUSION: This is the most comprehensive study evaluating the demographics of the national EMS workforce of active patient care providers. Understanding the characteristics of EMS professionals and the settings they practice in is important for educational and training initiatives, as well as protocols and policies.

Ultrasound Use in the Prehospital Setting for Trauma: A Systematic Review.

BACKGROUND: Trauma is a leading cause of death in the United States. Ultrasound use in the prehospital environment has the potential to change trauma management. Although ultrasound use for prehospital trauma is increasing, the role of this modality is not clearly defined. OBJECTIVES: We examined the use of prehospital ultrasound (PHUS) for trauma patients and the use by different provider types. Specific factors of interest were if prehospital ultrasound has been shown to improve providers' ability to recognize conditions that can be managed in the prehospital setting, treat these conditions, change transport destination, or improve overall mortality rates for trauma patients. METHODS: We searched MEDLINE/PubMed, EBSCOhost, Cochrane Library, and Embase medical literature databases for articles that addressed our outcomes. Abstracts and articles were examined and studies that did not specifically evaluate ultrasound in the prehospital setting for trauma and duplicates were eliminated. Studies included in this comprehensive review were assessed for the use of ultrasound in the prehospital setting to aid in the diagnosis, treatment, and transport of trauma patients. We also conducted an analysis of bias in the included articles. Due to the large heterogeneity in the included studies, no meta-analysis could be performed. RESULTS: Sixteen studies were identified comprising 3,317 patients. One study evaluated Emergency Medical Services (EMS) professionals as the ultrasound operator while five studies involved mixed practitioners and ten studies involved only physicians. Diagnostic accuracy was similar amongst physicians and mixed practitioners with no studies reporting PHUS accuracy for EMS providers alone. Seven studies evaluated treatment and transport impact of PHUS though the variables measured were inconsistent and results varied by protocol and outcomes measured. There were no studies that evaluated PHUS and its impact on patient mortality. CONCLUSION: Ultrasound use in the prehospital setting for trauma is feasible and demonstrates potential. However, the evidence in the medical literature mainly consists of prospective observational studies of physicians utilizing ultrasound for trauma in a HEMS setting. Further scientific research must be undertaken to firmly establish the role of prehospital ultrasound in trauma management by all types of EMS providers.

Comparison of Volunteer and Paid EMS Professionals in the United States.

BACKGROUND: Emergency medical response is provided by volunteer emergency medical services (EMS) professionals in many parts of the United States. However, little is known about those who serve as volunteer EMS professionals, especially as their main EMS job. Our objective was to compare the characteristics of nationally-certified volunteer versus paid EMS professionals in the U.S. Methods: We conducted a cross-sectional evaluation of EMS professionals who recertified their National EMS Certification between October 1, 2017-March 31, 2018 or October 1, 2018-March 31, 2019. Data were obtained from 2 cycles of the biennial National EMS Certification recertification application. We included currently working, nonmilitary EMS professionals aged 18-85 years at the emergency medical technician (EMT) or higher certification level. Volunteer was defined as receiving nominal or no compensation for the provision of EMS services at an agency as the main EMS job. Comparisons were made, accounting for the large sample size, to determine notable differences between volunteer and paid EMS professionals. Results: Of the 154,229 EMS professionals that met inclusion criteria (response rate = 86%), 13% volunteered at their main EMS job. More volunteer than paid EMS professionals were female (38% vs. 22%). There was also a significant difference in certification level between volunteer and paid (EMT: 82% vs. 46%). Three-quarters (74%) of volunteer EMS professionals reported working in rural communities compared to 30% of paid. The states with the largest proportion of volunteers to any currently working EMS professionals who recertified were Vermont (47%) and North Dakota (45%). Conclusion: Approximately 13% of the EMS workforce held a primary job in EMS as a volunteer, and these volunteer EMS professionals differed from their paid counterparts - e.g., volunteers were more likely to be women, have EMT certification, and work in rural areas. We encourage further research to understand motivations for volunteering in EMS.

Comparison of Air Force, Army, and Navy Emergency Medical Technician Candidates' Performance on the National Registry Cognitive Examination.

INTRODUCTION: Military medics function similarly to civilian emergency medical technicians (EMTs); however, they perform their emergency medical care in combat zones and military treatment facilities. Both civilian and military EMTs must take and pass the National Registry of EMT's cognitive examination to be certified as a Nationally Registered EMT; however, there is a discrepancy in requirements for obtaining and maintaining National EMT Certification between the military branches of the DoD. In our study, we aimed to compare the performance of the U.S. Air Force (USAF), U.S. Army (USA), and U.S. Navy (USN) EMT candidates on the National EMT Certification cognitive examination from 2015 to 2017. MATERIALS AND METHODS: We performed a cross-sectional analysis of the National Registry of EMT's database for the examination results of all military EMT candidates who attempted the National EMT Certification cognitive examination between January 1, 2015, and December 31, 2017. First and cumulative third attempt pass rates and cognitive performance from mean ability estimates (MAEs) on the examination were assessed. Descriptive statistics were calculated and comparisons between branches with regard to passing rates and MAEs were made using chi-square tests and ANOVA, respectively, at the alpha level of 0.05. RESULTS: During the 3-year study period, a total of 3,642 USAF, 14,050 USA, and 1,187 USN candidates attempted the cognitive examination one or more times. The USA candidates demonstrated the highest first attempt pass rates (2015: 78%; 2016: 78%; and 2017: 81%) followed by the USAF candidates (2015: 58%; 2016: 62%; and 2017: 64%) and the USN candidates (2015: 41%; 2016: 56%; and 2017: 62%). The cumulative third attempt pass rates followed a similar trend (e.g., USA: 2015: 94%; 2016: 95%; and 2017: 96%). These differences by branch were statistically significant for each year (P < .001). The overall test MAE scores also differed by branch, but only the USN candidates' MAE scores differed by year. The USA candidates demonstrated the highest MAE from 2015 to 2017 (523) followed by the USAF (489) and the USN (464) candidates. The overall test MAE scores for the USN candidates improved over the study period (2015: 449; 2016: 475; and 2017: 479, P < .001). CONCLUSION: Military EMT candidates had different performances on the EMT cognitive examination between branches. The USA candidates demonstrated higher pass rates and cognitive performance on the examination compared to their counterparts from the USAF and USN from 2015 to 2017. Further work should be directed at defining the cause of the differences in military EMT candidate performance and determining the characteristics that impact these differences.