Howard Backer, MD, MPH, FACEP
Emergency Medical Responder Classification in California
In 1998, the National Highway Transportation Safety Administration (NHTSA) and the National Association of State EMS Officials (NASEMSO) released a comprehensive five-part plan to move the national EMS system and the profession of EMS forward. The resulting plan, named the "Emergency Medical Services Education Agenda for the Future: A Systems Approach" and referred to as the "Education Agenda," reflects the belief that the EMS community should seek to enhance EMS as an allied health profession by promoting standardization. One component of the plan was the National EMS Scope of Practice Model released in 2006 that revised provider levels.
While states are not required to implement the NHTSA’s model, the Emergency Medical Services Authority considers standardization of the EMS levels of practice, along with their training and basic scope or practice nationwide to be a worthwhile goal. California now uses the National Registry Exam for certification and licensing of EMS personnel, and the exam content is changing to meet the new national requirements.
Over the past year EMSA has been working closely with our stakeholder groups on regulatory revisions to align California’s EMS provider classifications with the national model. We’ve been working with a task force to revise the existing regulations “First Aid Standards for Public Safety Personnel” to incorporate the new provider level Emergency Medical Responder (EMR). EMR is a level used primarily by public safety and some non-transporting responders. In California, some of the agencies that currently train to this level and their estimates of the current number of staff trained, include CHP (7400), Cal Fire (3600), and Parks and Recreation (700). As proposed by the NHTSA, an EMR has a scope of practice between First Aid and EMT. Compared to an EMT, EMR training does not require clinical hours; and an EMR cannot transport a patient, assist the patient in administering prescribed medications, or use a variety of airway and diagnostic devices.
In April, 2011, the EMSA task force completed its work and released draft regulations which recommend: 1) Changing the title of this chapter to “Standards and Training for Public Safety Personnel and Emergency Medical Responder”; 2) Provisions for optional tactical first aid training for law enforcement personnel; 3) A proposed scope of practice for public safety first trained personnel; 4) A proposed scope of practice for EMR consistent with the National Scope of Practice Model; and 5) Training standards for both public safety personnel and EMR.
Before the regulations were completed, a bill was introduced in the Legislature that would have defined EMR as a training standard only, and prevented EMSA from creating regulations to define a scope of practice for an EMR classification. The bill, AB 1245, made it through both houses but had strong opposition. Governor Brown did not sign or veto the bill and asked that EMS stakeholders try to work out a compromise. It was apparent that more work needed to be done to clarify the intended use of EMR, the potential benefit of creating EMR in statute, and the appropriate scope of practice, training and screening requirements.
EMSA agreed to host the meetings and engaged a facilitator to ensure that the meetings were productive. Participants included EMSA, California Professional Firefighters, California Department of Forestry and Fire Protection, California State Parks, California Highway Patrol, Regional Council of Rural Counties, National Ski Patrol/Ski Industry, California Professional Firefighters, California State Firefighters, California State Sheriff’s Association, California Police Chiefs Association, EMS Administrators Association, California Ambulance Association and American Civil Liberties Union.
Over two full days of discussion in February and March, the participants reached the following general points of agreement:
1) The EMR classification should be formally implemented in California through statute and regulation.
2) EMR training standards should meet criteria established in regulation, which is expected to be similar to the national standard.
3) EMRs should be certified by the local EMS Agency or a certifying entity in a manner similar to that which currently exists for the EMT-I classification, and they should be included in the California Central Registry
4) EMRs should be subject to a Department of Justice/FBI criminal records check with subsequent arrest notification.
5) Public safety personnel for whom a DOJ/FBI background check with subsequent arrest notification is a requirement of employment should not be required to complete an additional background check to be certified as an EMR for that employer.
6) National Ski Patrol members who are trained in Emergency Outdoor Care, which includes the EMR scope of practice, should be recognized to render aid within that training but should not be required to have a background check while serving solely in the capacity of a Ski Patroller.
7) Every effort should be made to reduce costs associated with certification, Central Registry, and background checks.
Although these ideas were agreed to in principle, we did not require that each participant organization commit to supporting every aspect of the final proposal. At this point, these points will be recommendations to the legislature. Now draft legislation and its analysis can move forward in the standard way with organizations supporting or opposing concepts as they perceive them to affect their membership. Major concerns that remain are costs that may discourage rural area volunteers and agencies with large numbers of these staff, and concerns that some agencies will downgrade staff from EMT to EMR.
EMSA will remain engaged in this process and we look forward to further constructive discussion as EMR implementation moves forward.
EMS Regulations Update
Emergency Medical Technician (EMT) Regulations
By Adam Willoughby
Following three public comment periods, the proposed changes to the EMT Regulations received unanimous approval by the EMS Commission March 21st. The four main regulation changes are: 1) Incorporate the National EMS Education Standards for EMT training; 2) Increase the required EMT course hours from 120 to 160 hours (136 hours of didactic training and 24 hours of clinical experience) and the minimum number of patient contacts from 5 to 10; 3) Amend the scope of practice to mirror the National EMS Scope of Practice Model; and 4) Clean-up sections of the regulations to provide more clarity. EMSA will now submit the final rulemaking file to the Office of Administrative Law for review and approval. The revised EMT Regulations are expected to go into effect by late June 2012.
Advanced Emergency Medical Technicians (AEMT) Regulations
Proposed AEMT regulation changes have already undergone three public comment periods, and will soon begin a fourth intended to clarify provisions related to base station coordinators. The five main regulation changes currently under consideration are: 1) Incorporate the National EMS Education Standards for AEMT training; 2) Increase the required minimum AEMT course hours from 88 to 160 hours (80 hours of didactic instruction, 40 hours of clinical experience, and 40 hours of field internship); 3) Amend the scope of practice to mirror the National EMS Scope of Practice Model; 4) Clean-up sections of the regulations to provide more clarity; and 5) Update sections pertaining to Base Hospital accreditation and base coordinator requirements.
The revised Paramedic regulations were open for public comment from September 9, 2011 to October 24, 2012. EMSA is currently reviewing the proposed amendments in light of public feedback. Specifically, EMSA is working to determine which scope of practice items will be included in the basic scope and which items will be included in the local optional scope. Once this process is completed the proposed amendments will be released for an additional 15 day public comment period. The three main regulation changes currently under consideration are: 1) Scope changes to Advanced Prehospital Paramedic (APP); 2) Increasing the minimum hours of required training for Critical Care Paramedic (CCP) to 202 hours from 120 hours; and 3) Removing altogether and/or modifying components of basic and local optional Paramedic scope of practice items.
Public Safety and Emergency Medical Responder Regulations
The EMS Authority has been working with a task force to revise the existing regulations “First Aid Standards for Public Safety Personnel.” In April, 2011, the task force completed its work and released draft regulations which recommend: 1) Changing the title of this chapter to “Standards and Training for Public Safety Personnel and Emergency Medical Responder”; 2) Provisions for optional tactical first aid training for law enforcement personnel; 3) A proposed scope of practice for public safety first trained personnel; 4) A proposed scope of practice for EMR consistent with the National Scope of Practice Model; and 5) Training standards for both public safety personnel and EMR. The EMR training standards are proposed to be consistent with the U.S. D.O.T. Educational Standards and Instructional Guidelines.
However, due to significant stakeholder concerns related to implementation of the EMR provider category, progress on this effort was delayed pending legislative action. More information about that is available in Dr. Backer's message above.
Stroke and STEMI Systems Regulations
The local EMS agencies (LEMSA) continue to develop local optional Stroke Care Systems and/or STEMI Care Systems to include facility recognition, destination policy, quality improvement process, and data collection. In October 2011, the EMS Authority contracted with North Coast EMS Agency to develop STEMI and Stroke Systems regulations in California. A working group of EMS partners and other stakeholders which might be impacted by these regulations has been identified to participate in the regulatory development process. The first priority has been to create a document of data elements and benchmarks for STEMI and Stroke care systems, which took place February 6th. Each set of regulations will be on a two year timeline ending June 2013.
EMS for Children Regulations
The EMS Authority and numerous EMS system participants with a special interest in pediatric EMS issues have developed draft EMS for Children Regulations which are out for pre-public comment until April 16, 2012. The EMS Authority contracted with Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center to develop regulations for destination policy, pre-hospital and hospital data collection, and quality improvement processes for children’s emergency medical facilities. After responding to pre-public comments, EMS Authority will post the draft for public comments periods in California.
For additional information relating to EMS regulation changes, visit EMSA’s Public Comment page here.
See Something? Say Something!
By Adam Willoughby
In the post 9/11 world, we all have a responsibility to be aware of our surroundings and to take note of things that just don’t look right. EMS responders, more than most, are in a perfect position to contribute eyes and ears on the ground in every corner of the community.
Imagine for a moment that you receive a call for a man down and you find him unconscious in a house with almost no furniture and there’s a map of the streets around City Hall on the wall. Would you be suspicious? Would you hesitate to tell authorities because you might be wrong? The “See Something, Say Something” program, operated by the U.S. Department of Homeland Security (DHS) exists to make that decision easier.
The program includes designated “Terrorism Liaison Officers” (TLOs) and regional “Fusion Centers” which act as information conduits – collecting information from a variety of sources and disseminating information to local authorities as needed. The TLOs work with law local authorities and those within their profession as a visible representative and resource of the See Something, Say Something program.
This program encourages individuals to keep their antennae up and report anything that appears suspicious. “EMS responders can tell their organization’s TLO or law enforcement what they saw and that information will be given to the fusion center which will analyze the information and make the decision about whether action is needed. If it turns out to be nothing, no harm done,” explained EMSA Terrorism Liaison Officer Craig Johnson.
Emergency responders play a crucial role in this effort due to the fact that they regularly traverse areas within their response area and are afforded access to many private residences and places of business. Consequently EMS personnel must maintain a high degree of situational awareness and report to their TLO or law enforcement any observed suspicious activity, which may include:
- Unusual questions, monitoring, sketching, photography, or map-making at/near key facilities
- Intelligence collection/attempts to gather information via mail, email, fax, telephone, and/or face to face on target facilities
- Unusual interest in or attempts to purchase or obtain Chemicals, explosives, or large quantities of household cleansers or beauty supplies
- Official vehicles, uniforms, badges, access cards or official identification
- Presence of individuals who cannot explain their need to be at/near key facilities
- Unusual questions or circumstances surrounding the possession or reported theft of passports, visas, or other travel identification or documents
- Attempts to test or penetrate security or response procedures
- Unusual money transfers or transactions involving overseas persons or businesses
- Cyberspace attacks - As the Internet becomes more pervasive in all aspects of our lives, individuals or groups can use the anonymity of cyberspace to elicit information to cause harm. This may be a difficult one to identify and report, but at the very least, be aware of such attacks and be judicial in your cyberspace use
“Serving as a TLO is a role I take seriously. What happened on 9/11/2001 was a wake-up call for me and something I wish to never see again. As a TLO I can help thwart terrorism by staying informed and being a conduit of information between the public safety community and the Fusion Centers,” added Johnson.
Learn more about what you’re looking for and what to do when you see it at www.dhs.gov/files/reportincidents/see-something-say-something.shtm.
A look at the Commission on Emergency Medical Services
By Robin R. Robinson
If you’ve ever wondered who’s influencing EMS policy in California, the answer is – everyone! When the Legislature created the Emergency Medical Services Authority, they also created a public Commission made up of organizations with a stake in EMS to provide advice and approve EMS regulations, standards and guidelines. The make-up of the Commission has changed a bit over 30 years, but it currently includes the following 18 members:
Appointed by the Governor
One county health officer nominated by the California Conference of Local Health Officers:
David Herfindahl, M.D., FAAFP (Retired) Community Health Agency
One registered nurse with experience as a mobile intensive care nurse nominated by the California Emergency Nurses Association:
Matt Powers, RN, MS, EMT-P, North County Fire Authority, San Mateo County
One management member of an entity providing fire protection and prevention services nominated by California Fire Chiefs Association:
Sheldon Gilbert, Alameda County Fire Department, San Leandro
One hospital administrator of a base station hospital nominated by the California Hospital Association:
Chris Van Gorder, Scripps Health, San Diego
One full-time peace officer who is either an EMT-II or paramedic nominated by the California Peace Officers Association:
Colleen Kuhn, EMT-P, San Bernardino County Sheriff’s Department, Hesperia
One public member who has experience in local EMS policy issues and who resides in a rural area:
Chuck Baucom, EMT-P, Public Member (Rural), Merced
One public member who has experience in local EMS policy issues:
Aaron F. Hamilton, EMT-P, GPS Logic, Laguna Hills
One administrator from a local EMS agency nominated by the Emergency Medical Services Administrators Association of California:
Bruce Barton, EMT-P, Riverside County EMS Agency, Riverside
One person who is an active member of the California State Firefighters Association:
Lew Stone, California Professional Firefighters
One person who is employed by a city, county, or special district that provides fire protection nominated by the California Professional Firefighters:
David Rose, EMT-P, Santa Clara Fire Department, Santa Clara
One medical director of a local EMS agency nominated by the EMS Medical Directors Association of California: Not Pictured. Eric Rudnick, M.D., NorCal EMS, Redding
One person who is employed by the California Department of Forestry and Fire Protection: Not Pictured. Dave Teter, Battalion Chief, EMT-P, Department of Forestry and Fire Protection
Appointed by the Senate Rules Committee
One full-time physician and surgeon, whose primary practice is emergency medicine nominated by the California Chapter of the American College of Emergency Physicians:
Ramon Johnson. M.D., Mission Viejo Emergency Medicine Associates, Mission Viejo
One physician and surgeon who is a trauma surgeon nominated by the California Medical Association:
Dev A. GnanaDev, M.D., MBA, Arrowhead Regional Medical Center, Colton
One full-time paramedic or EMT-II, who is not employed as a full-time peace officer nominated by the California Rescue Paramedic Association:
Jane Smith, EMT-P, San Francisco Paramedic Association
Appointed by the Speaker of the Assembly
One physician and surgeon, who is a trauma surgeon nominated by the California Chapter of the American College of Surgeons:
Daniel Margulies, M.D., Cedars-Sinai Medical Center, Los Angeles
One physician and surgeon who is board eligible or board certified in the specialty of emergency medicine by the American Board of Emergency:
Eugene Hardin, M.D., Carson Medical Group, Carson
One pre-hospital emergency medical service provider from the private sector nominated by the California Ambulance Association: Not Pictured. Jaison Chand, RN, BSN,, EMT-P, City Ambulance of Eureka, Inc., Eureka
For more detailed information about the Commission and the specific functions of its officers and their duties visit www.emsa.ca.gov/commission/RevisedCommissionBy-Laws.doc.
The Commission meets quarterly in various locations within the state of California. The agenda items up for discussion are detailed on EMSA’s website at www.emsa.ca.gov/meetings/2012/03-21-12/default.asp. Dates and locations for the remaining 2012 Commission meetings are as follows:
- June 20, 2012, Hilton Arden West, 2200 Harvard Street, Sacramento, CA 95815
- September 19, 2012, Kona Kai Hotel, 1551 Shelter Island Drive, San Diego, CA 92106
- December 5, 2012, Marines’ Memorial Club & Hotel, 609 Sutter Street, San Francisco, CA 94102
All meetings are held on Wednesdays at 10 a.m. and usually conclude by 12:30 p.m.
How Many Paramedics are there in Kings County?
Believe it or not, the Central Registry of EMS Personnel has been up and running for almost two years now. All of the work EMSA and other EMS stakeholders put into this project is being rewarded with access to real-time accurate statistics about EMS personnel statewide.
The utility of this system makes it possible to look at the big picture and know that 78,862 people hold a license or certification in some status at this moment. We can narrow our view to see that the guy in the office next to me has paramedic license number P-00001 and it is in good standing.
We can also see how many EMS personnel currently exist by provider category and county. What do you think? What kind of questions do you have about our EMS system that we could answer by querying the Central Registry? Ask and we’ll do our best to get you an answer.
EMSA Employee of the Quarter:
Cecile Freeman, Fiscal and Administration Unit Manager
Cecile Freeman, manager of EMSA’s Fiscal and Administration Unit, has been selected as EMSA’s Employee of the Quarter due to her excellent customer service, commitment to quality, and responsiveness to meeting the needs of the department.
Cecile has worked for the State of California for 28 years, and has been a valued member of our team at EMSA for the past five years. She was promoted to the manager position about a year ago and demonstrated incredible leadership, tenacity and the ability to multi-task while supporting our move to Rancho Cordova and simultaneously adapting to a new management role.
Cecile has quickly grown into a strong manager and has worked to develop her team while appreciating all of their many unique strengths. She has introduced new time-saving cost-saving processes and streamlined some functions in the department while ensuring that we have everything we need to perform our responsibilities. Most importantly, Cecile sets an example for us all by consistently providing service with a smile.
Cecile is a life long resident of West Sacramento and a 3rd generation of the area as well. She attended Sacramento City College and graduated with my A.A. (Social Science) in 1984. Before coming to work for the State, Cecile was worked at the local parks & recreation district and the local school district.
Cecile’s passions are her family, theater and Disneyland. In June of 2012, she and her husband Tracy celebrate their 30th wedding anniversary. Their daughter, Tracey Leigh Freeman, is a professional actor, singer and dancer in musical theater.
Thank you for your contributions to EMSA and to the work we all do for the State of California.