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Paramedics and scope of practice

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Highly-trained paramedics can initiate the pathway of care that will achieve optimal outcomes for patients

The question, posed to me by the Journal’s editorial staff, “Are paramedics exceeding the evidence?”, is a very global one that implies a dichotomous response. However, nothing in our complex health system can be so simply evaluated, so the question gets an equally global (if vague and unhelpful) answer: “Yes, probably, but no more or less than the rest of health care”.

My professional obsession with objective analysis must necessarily be tempered in this instance by my experience in contributing to the professional transformation of the ambulance service, particularly in the 1990s. This transformation resulted in considerable expansion of the scope of practice, underpinned by improved education and training — from in-house unstructured training, through the vocational training sector to university degrees.

The transformation in prehospital care was largely driven, not by evidence, but by the enthusiasm of proponents (mostly doctors) and by emerging international experience. The intellectual foundation was not usually evidence, but rather a defensible and logical rationale. Innovation is often so, because we cannot test system-wide effectiveness without introducing system-wide changes. However, sometimes that rationale is flawed when we make the “conclusional”…