Paramedics generally receive their education through programs offered by community colleges or agency-based education programs that are recognized by CDPHE. Paramedic programs are required to be affiliated with an academic institution and have relationships with multiple clinical organizations. Additionally, paramedic programs must be accredited by the National Commission on Accreditation of Allied Health Education Programs.
Colorado, like most states, uses the National Scope of Practice Model as the foundation for its EMS providers’ scopes of practice. The National Scope of Practice Model is reviewed and updated regularly to assure that the Scope of Practice meets the needs of patients and reflects the latest evidence-based guidelines. As a part of the review process, EMS education experts work to assure that the Scope of Practice does not include skills for which there is no training, and that the National Education Standards are updated to meet the needs of the next generation National Scope of Practice Model. In essence, there are 4 “legs” on the “stool” of EMS clinical practice. The National Scope of Practice is typically updated every 7-10 years by a review of national practice data (what are paramedics being asked to do?), the latest evidence on clinical practice (does this drug work or is this device now obsolete?), and, to some extent, data from national credentialing (individuals) and accrediting organizations (training institutions). The National Scope of Practice then influences the National Education Standards (what do clinicians need to be taught in order to perform the Scope of Practice?). Training Program Accreditation Standards are then updated to assure that training organizations teach to the National Education Standards. The fourth leg, the National Registry of Emergency Medical Technicians, a national testing organization, writes and administers tests that assure that students have actually learned the objectives incorporated in the National Education Standards.
Unlike many other types of regulations that set minimum standards, Colorado’s scope of practice regulations set a ceiling; paramedics are not authorized to perform any acts/skills/medications that are not specifically listed in the regulations. Based on Colorado’s unique needs and stakeholder input, CDPHE may insert acts/skills/medications that are not within the National Education Standards into its scope of practice rules. Consequently, CDPHE requires that education programs teach students Colorado’s scope of practice.
In reviewing the education content for paramedics, the panel found strong emphasis on some subjects and less or none on others. The content focuses heavily on pharmacology, including drug classes such as sedatives, antipsychotics and dissociatives. The topics of drug indications, contraindications, dosage, and administration are emphasized, while complications and monitoring are less discussed. Education on behavioral illnesses is limited. The focus tends to be on evaluation of suicide potential and threat to EMS personnel. Content on agitated delirium focuses on identifying the metabolic cause and does not include information on de-escalation. A review of a local education program indicated that the behavioral illness content consisted of readings only, with no lectures or skill sessions. The panel agreed that EMS education as a whole is lacking in behavioral health content and suggested that this critical content be addressed as education standards are updated.
Importantly, content on implicit bias is non-existent. In fact, the word “bias” is mentioned only three times in the National Education Standards, not one of which is related to patients. As far as content related to the paramedic’s responsibility for decision-making, there is substantial coverage on patient consent and evaluation of decision-making capacity, the role of medical direction, and paramedic clinical decisions. Conversely, the content is sparse and there is mixed messaging concerning paramedics' interactions with law enforcement and transitions of care. Consequently, the panel reiterates that training on bias, transitions of care, and interacting with law enforcement must be provided by a paramedic’s medical director and/or EMS agency.
The manner in which paramedics are educated provides important context to the issues considered by the panel. Paramedic clinical practice relies heavily on clinical guidelines/protocols. Paramedics are most likely to meet performance expectations consistently when they encounter medical or behavioral issues that are well defined, common, and have clear definitions and well-aligned protocols as is seen with many medical conditions (e.g., cardiac arrest, stroke and ST elevation myocardial infarction or STEMI). Conversely, the greatest clinical variability in the prehospital setting occurs in conditions that are infrequent or poorly defined. The lack of guidelines or the existence of poorly-defined protocols force paramedics to improvise or to provide care based on guidelines for a problem that appears to be “similar” (headache, non-specific abdominal pain, unusual diseases). Since the excited delirium diagnosis is relatively infrequent and poorly defined with no well-aligned guidelines, it is not surprising that clinical performance is inconsistent.
The panel understands the complexities involved when adding content to a curriculum. Subject matter experts described some of the barriers that education programs encounter when they try to incorporate new and different content into the curriculum. Covering existing content in a 1500-2000 hour program is already difficult and adding more content, even in the important areas of racism, bias, restraints, and behavioral health, poses significant time, cost, and practical concerns.
These concerns are even more challenging in Colorado’s rural areas.[57] Forty-seven of Colorado’s 64 counties are designated as rural or frontier.[58] In these areas, EMS providers often volunteer for their local community agency while also working full time at their “real jobs.” Availability of more skilled providers such as paramedics is limited and some areas have no paramedics at all. In order to become a paramedic, these individuals often have to commute from their communities to urban areas to attend courses, which is costly and inconvenient. The panel acknowledges these difficulties and understands that national and/or state changes to the paramedic educational curriculum will take time.
PANEL RECOMMENDATIONS
Colorado should expand its paramedic curriculum, as detailed above, to ensure that paramedics receive timely and relevant education on topics and skills, including racial equity and explicit/implicit bias, that are vital to the proper administration of ketamine as a chemical restraint.
Paramedics should be required to take continuing education courses on racial equity, explicit/implicit bias, and patient hand-off for renewal of a certification/license, until these topics can be integrated into paramedics' initial education. (See Recommendations A.2 and D.4)
CDPHE should require EMS medical directors to train their paramedics on these topics as a condition of receiving a ketamine waiver. (See Recommendation D.4)