Role of Emergency Medical Technicians and Paramedics: Observer-Trainees

The paramedic trainee has had three years of ambulance experience and eighty additional hours of classroom training in emergency care. He is currently enrolled in additional classes. In order to receive state certification as a paramedic, he must also work a specified number of hours in the emergency department. Tonight is his first shift. What should his role be in the emergency department?

Because emergency de­partments often deal with severely traumatized patients, necessitating immediate critical decisions and procedures, perhaps his role should be confined to that of passive observer. On the other hand, he needs to acquire knowledge and skills by making decisions and performing procedures under pressure.


For example, he needs to learn to intubate a patient, a procedure which involves placing a tube into the trachea of someone who has stopped breathing. If this procedure is not done promptly and appropriately, the patient will die (although the patient can usually be maintained marginally by placing a mask over his mouth and breathing for him with a bag ventilator).

Paramedics, intermediate level emergency medical technicians (IEMTs), residents, and medical students all need to learn to intubate patients under critical circumstances. A paramedic who is inexpe­rienced with this procedure may lose a life he otherwise could have saved. If a patient stops breathing in the emergency department, should the paramedic trainee be allowed the first try at intubating the patient?


Commentary

It should be noted that the questions raised by this case are not restricted to the paramedic trainee but arise in most areas of medical training. One could argue, for example, that an intern and a resident physician are learning in the emergency facility as well and, therefore, they are subject to the same constraints as a paramedic trainee.

IMPORTANCE OF PRECLINICAL TRAINING


In most instances, this situation is dealt with by making sure that a trainee is appropriately instructed in the theory, at least, of what it is he is about to do. Thus, for example, a trainee would not be expected to intubate a patient de novo but rather would have had many hours of instruction as to the indications for intubation, the nature of the technique, and the expected complications.

Thus, an ideal model already would have been presented to the student. And by the time he reaches the emergency department, the trainee probably has practiced the technique on models that were available: manikins, animals, or cadavers.


Most people would probably agree that it is important for a paramedic to receive adequate training in emergency medical procedures, since he is expected to use these procedures to save lives. The acquisition of appropriate experience, however, should not be at the expense of any individual needing emergency care.

Certainly, a patient in the emergency department should be told who the trainees are, and if possible, the patient should give his informed consent to being treated by persons who are at various stages of training, both paramedic and physician alike. In any teaching hospital, it is routine to inform patients that physicians in training will be looking after them under the supervision of attending physicians. In the case of a critically ill patient who may not be able to give consent prospectively, the responsibility for assuring that adequate care is given rests with the attending emergency physician.


The attending physician in this case must act as the patient's advocate. Thus, prior to the paramedic trainee's being allowed to intubate a patient, the attending emergency physician would have assured himself that the trainee had undergone appropriate instruction in the procedure, that he understood the nature of the procedure to be done, and that he had observed it being performed in a number of instances.

The degree of involvement of the trainee in the care of patients would increase over the course of his rotation through the emergency department. In the initial stages, the paramedic trainee would be primarily an observer, and toward the end of his tenure in the emergency department, he would be an active participant whose skills would have been considerably more realized.

At the appropriate time in his training a paramedic trainee would be allowed to insert an endotracheal tube, although it is to be expected that the attending physician may have to intervene and complete the procedure.


In this case, if the procedure were done appropriately, the risk to the patient would be minimal; for example, the patient could be adequately preoxygenated, all other appropriate mea­sures could be taken, and so a certain amount of time would be available for the paramedic trainee to perform the procedure without having to rush through it at break-neck speed. In this way the worthwhile goal of training the paramedic in intubation will have been accomplished without any serious risk to the patient. Although there may be some degree of additional risk to the patient created by the inexperience of the trainee, this risk is small and justifiable.

Generally, in a community with teaching hospitals, the patients have a great deal of forebearance with respect to the educational process within the institution. In fact, often the institution earns its reputation by virtue of its teaching programs. It is the expectation of the community that these teaching programs will be administered re­sponsibly.


The same is true in the emergency department. It is the expectation of the community that despite the training effort that must go on there, the trainees and the attending physicians who assume overall management of the patient will also assume the responsibility for giving their patients high-quality care.

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