New competencies of paramedics. Draft regulation

The Ministry of Health wants paramedics to perform minor surgeries, intubate with muscle relaxants and administer drugs previously prescribed by ambulance drivers. Anesthesiologists are against expanding the activities of care providers. – Many of them can only be performed in an operating room – they warn. Stakeholders are of the opinion that new competences are needed, but only on condition of appropriate training.

The Department of Health wants to expand the list of emergency paramedics to include those that can only be performed by a doctor today. The draft amendment to the Regulation on Medical Assistance and Health Services Other than Medical Assistance that may be provided by a paramedic provides that the provider performs urinary catheterization, ultrasound examination and endotracheal intubation using muscle relaxants and alternative ventilation. In addition, the care provider will administer the drugs that could previously only be prescribed by a doctor: dopamine, ketamine, methoxyflurane, prasugrel and tranexamic acid. Today is the deadline for submitting comments on the draft as part of public consultations.

The ministry explains that in the State Medical Rescue System system, there are more and more basic medical rescue teams (called “P” teams) without a doctor (teams with a doctor are called specialist teams or “S” teams). Therefore, paramedics often have to decide for themselves whether to perform such a procedure on a patient, and the obligation to consult this decision with a doctor extends the time of providing assistance to the patient. In addition, paramedics in the process have of undergraduate and postgraduate education are prepared for this activity” – we read in the motivation of the project.

Doctors on them

Doctors are outraged: “The fact that departing basic teams (ie teams in which only rescue workers travel, as opposed to specialized teams, which also have a doctor – editor’s note) are increasingly participating in the state medical emergency system makes it necessary to to perform intubation using skeletal muscle relaxants “- the Polish Society of Anesthesiology and Intensive Therapy (PTAiIT) wrote in its statement.

More severely, anesthesiologists criticized the right to administer drugs previously prescribed by physicians: “The expansion of the list of drugs approved for self-administration by a paramedic to include drugs used during general anesthesia, i.e. etomidate, ketamine and rocuronium, is unjustified and poses a threat to the health and life of patients. Their safe use requires training as part of the work of the anesthesiology team” – emphasizes PTAiIT.

Drug taken from operating theaters now available in ambulances?

The new powers of rescue workers are also opposed by the Polish Association of Emergency Medicine (PTMR): – For many years we have been consistently opposed to expanding medical powers to perform medical procedures – says Prof. Juliusz Jakubaszko, former president of PTMR , anesthesiologist and emergency physician. And he explains that some of the drugs that paramedics have to use in ambulances are no longer even used in operating rooms, where medics have equipment and medicines at their disposal.

– The use of methoxyflurane in anesthesiology has long been discontinued due to serious side effects – including: cardiac arrhythmias and drops in blood pressure. For this reason, it is no longer used, even in operating room conditions, and would it be used in ambulances? It’s dangerous – says Prof. Jakubaszko. – Nor can I imagine rescuers being able to use relaxants for endotracheal intubation, which today can only be used by specialist physicians, with full equipment and hospital protection – he adds.

Damian Patecki, anesthesiologist and member of the presidium of the Supreme Medical Council, also has doubts: – The scheme seems unprepared, not fully thought out and written by someone who does not know the reality of emergency medical services. I also don’t understand why paramedics should use dopamine – it’s a very potent drug that needs to be properly diluted, titrated and administered at the right concentration. There are no guidelines that say that dopamine should be administered as a first-line drug. They’re only used this way in pediatric anesthesiology, he notes.

Intubation is not for everyone

He also does not understand why the Ministry of Health wants to entrust care providers with the option of intubation: – In the motivation we read, for example, that care providers are well prepared for intubating patients. Meanwhile, intubations performed by the EMS are one of the most difficult, as they are performed on victims of accidents, injuries or burns. In these situations, intubation is not always good for the patient. I’ve had over 10,000 intubations myself, and I know there are patients I won’t even try to intubate — Patecki says. And he adds that there are other ways to open the airways, such as using supra-laryngeal devices or laryngeal masks.

What about the rescue workers themselves? Michał Madeyski, a paramedic from the Military Institute of Medicine who participates in military missions in the Middle East, notes that some of the powers that civilian rescuers would be entitled to have been granted to paramedics who spent three years in the armed forces.

– The order of the Minister of National Defense of March 8, 2019 expanded the activities of a military paramedic with 11 powers, including for minor surgery, administration of more drugs and antibiotics and intubation using muscle relaxants. At the same time, it took into account the specific circumstances in which they operate – ie the battlefield and lack of direct access to the health care system, both at home and abroad. However, expanding these powers in the case of military rescuers goes hand in hand with training and continued practice of skills once acquired, Madeyski says.

In the justification of the draft we read that “paramedics in the process of undergraduate and postgraduate training are prepared for this activity (intubation – ed.” frequent exercises, both on phantoms and under the supervision of experienced rescuers or doctors.

The victim of a fire should be intubated

According to Michał Madeyski, the approach to extend the powers of civilian rescuers needs to be more flexible. – In some situations there is an indication for absolute intubation, both on the battlefield and in civilian conditions. This is the case with fire victims who may have burns in their airways. Today, a paramedic cannot use muscle relaxants, so he can only intubate a person in cardiac arrest. Meanwhile, fire victims may not be deeply unconscious and still have a cough reflex when trying to put something down their throat. In order to save their lives, the paramedic must also use muscle relaxants, in accordance with the guidelines of international medical associations, he says. However, she stresses that new skills must be trained and then repeated regularly.

According to anesthesiologist Damian Patecki, some paramedics share the concerns of the medical community: – Many paramedics are well trained and aware of their competencies. They are afraid of people who are too ambitious and try to do things they cannot do. In rescue jargon they are called turboratniks – says Patecki. And he stipulates that not all solutions proposed by the Ministry of Health are inappropriate: – Research has shown the effectiveness of the use of tranexamic acid in stopping bleeding. It’s good that rescuers can use it – he thinks.

Main photo source: Shutterstock

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