Comparison of the Scope of Practice of the Army Combat Medic Specialist and Civilian National EMS Certification Levels

Abstract

Introduction

The transition of Army Combat Medic Specialists (Military Occupational Specialty Code: 68W) from military to civilian emergency medical services (EMS) is challenging, and the pathway is not clearly defined. Our objective was to evaluate the current military requirements for 68W and how they compare to the 2019 EMS National Scope of Practice Model (SoPM) for the civilian emergency medical technician (EMT) and advanced emergency medical technician (AEMT).

Methods

This was a cross-sectional evaluation of the 68W skill floor as defined by the Soldier’s Manual and Trainer’s Guide Healthcare Specialist and Medical Education and Demonstration of Individual Competence in comparison to the 2019 SoPM, which categorizes EMS tasks into seven skill categories. Military training documents were reviewed and extracted for specific information on military scope of practice and task-specific training requirements. Descriptive statistics were calculated.

Results

Army 68Ws were noted to perform all (59/59) tasks that coincide with the EMT SoPM. Further, Army 68W practiced above scope in the following skill categories: airway/ventilation (3 tasks); medication administration route (7 tasks); medical director approved medication (6 tasks); intravenous initiation maintenance fluids (4 tasks); and miscellaneous (1 task). Army 68W perform 96% (74/77) of tasks aligned with the AEMT SoPM, excluding tracheobronchial suctioning of an intubated patient, end-tidal CO₂ monitoring or waveform capnography, and inhaled nitrous oxide monitoring. Additionally, the 68W scope included six tasks that were above the SoPM for AEMT; airway/ventilation (2 tasks); medication administration route (2 tasks); and medical director approved medication (2 tasks).

Conclusions

The scope of practice of U.S. Army 68W Combat Medics aligns well with the civilian 2019 Scope of Practice Model for EMTs and AEMTs. Based on the comparative scope of practice analysis, transitioning from Army 68W Combat Medic to civilian AEMT would require minimal additional training. This represents a promising potential workforce to assist with EMS workforce challenges. Although aligning the scope of practice is a promising first step, future research is needed to assess the relationship of Army 68Ws training with state licensure and certification equivalency to facilitate this transition.

Introduction

Emergency medical services (EMS) professionals play a vital role in the continuum of care in the United States (US), serving as a critical link for patients to reach definitive surgical or medical treatment (1). Recently, there has been an increase in the overall use of the EMS system that has outpaced population density (2, 3). Based on this, an expectation of a 15% increase in demand for EMS services by 2030 requires, at minimum, an increase in 40,000 EMS professionals (4, 5). Further, in the face of concerns with a shortage of workforce members providing patient care, mechanisms to supplement the current EMS workforce with skilled, well-trained clinicians may be part of a possible solution to maintain future emergency care infrastructure.

One possible source to add to the civilian EMS workforce may be Army Combat Medic Specialists (Military Occupational Specialty Code: 68W) who have transitioned from the military to the civilian workforce. Army 68Ws are a well-trained pool of EMS professionals responsible for the medical care of service members in combat and garrison operations (6). Army 68W candidates undergo advanced individual training after basic training, spending the first 6 weeks completing the requirements for emergency medical technician (EMT) certification. This culminates in national certification at the (civilian) EMT level by passing the National Registry EMT cognitive examination and an Army psychomotor examination. Following this process, the next 10 weeks are spent learning battlefield injury care skills specialized to the Army 68W role, including advanced tactical combat casualty care core skills. While the training of 68Ws seems amenable to a transition to civilian EMS, there has been no formal evaluation of how well the Army 68W scope of practice and training aligns with the 2019 EMS National Scope of Practice Model (SoPM) (1) for both civilian EMT and advanced emergency medical technicians (AEMT).

Our objective was to present a comparative analysis between the scopes of practice for U.S. Army 68W combat medics and civilian EMTs and AEMTs. Specifically, we compared Army 68W training to the 2019 SoPM for the civilian EMT and AEMT to determine what additional training, if any, may be required to facilitate the transition of an Army 68W to a civilian EMT or AEMT. We hypothesized that the scope of practice and training of Army 68Ws would at least meet, and in some cases exceed, that of their civilian EMT and AEMT counterparts.

Methods

Study Design

A cross-sectional comparative analysis of the scopes of practice of U.S. Army 68W combat medics and civilian EMTs and AEMTs was performed. Military training regulations and government documents were reviewed and relevant data were extracted for Army 68Ws at skill level 1. There are three military skill levels, which are based on the soldier’s grade. The “floor” is considered skill level 1 for military grades E1 through E4, skill level 2 for grade E5, and skill level 3 for grades E6 and E7. Thus, skill level 1 was chosen for comparison to the civilian 2019 EMS SoPM to allow for the most inclusive and generalizable comparisons to be made. The extracted information for Army 68Ws at their basic level of competency was then compared to the 2019 EMS SoPM for civilian EMTs and AEMTs. Data collection occurred in March of 2020.

Measures

Civilian EMS clinicians have four national certification levels in the US: emergency medical responder, EMT, AEMT, and paramedic (1). The national civilian EMS scope of practice model was revised in 2019 and provides a framework for the floor of EMS care by defining the practice of EMS clinicians at each of the four levels of national certification, respectively (7) (Figure 1). This analysis focused specifically on the EMT and AEMT national certification levels. The initial training of EMT and AEMT levels vary across states and program type, but typically consists of ∼150 hours for EMT and 200-400 hours for AEMT (8). Competency is verified in most states after completion of a state-approved training program and attainment of national certification.

Figure 1. National guidelines and training documents that define the floor of practice for civilian and military EMS and their associated certification levels. Abbreviations: EMT, emergency medical technician; AEMT, advanced emergency medical technician; EMS, emergency medical services; 68W, army combat medic specialists; ATR, army training requirements.

The floor of Army 68W practice is defined by Training Circular 8-800 (TC8-800; Medical Education and Demonstration of Individual Competence) and STP8-68W13-SM-TG (Soldier’s Manual and Trainer’s Guide Healthcare Specialist) (6, 9) (Figure 1). TC8-800 is the official guidance on sustainment and also provides validation testing for 68W. Along with the TC8-800, the STP8-68W13-SM-TG is used for training and evaluating 68W soldiers on critical tasks that support unit missions during wartime. The floor of the STP8-68W13-SM-TG covers eleven subject areas, and the TC 8-800 covers seven major medical and trauma skills and one validation table.

After 10 weeks of basic training, Army 68W candidates undergo 16 weeks of advanced individual training (AIT) at Medical Education and Training Campus in Fort Sam Houston. Candidates spend the first 6 weeks completing the requirements for EMT certification, followed by the required earning of national certification at the EMT level by passing both the National Registry EMT cognitive examination and an Army psychomotor examination. Students who fail to earn national certification do not progress to the next level of Army 68W training. Following this process, the next 10 weeks are spent learning advanced tactical combat casualty care core skills specialized to the Army 68W role.

Data Extraction

Regulations and governmental documents were reviewed and extracted for specific information on military standard operating procedures and training. Extraction of Army 68W data was conducted by two independent military researchers (CBM, RC). The interpretive guidelines from the civilian 2019 SoPM were used as a template reporting form. There were seven skill categories evaluated: airway/ventilation/oxygenation, cardiovascular/circulation, splinting/spinal motion restriction/patient restraint, medication administration routes, medical director approved medications, initiation/maintenance of fluids, and miscellaneous. Related tasks were then identified under each skill category. Tasks identified from the military regulations and government documents were compared to those described in the civilian 2019 SoPM. Extractors referred to the EMT Educational Standards and Instructional Guidelines for definitions of each task (10). All tasks were classified into one of the seven skill categories listed above.

Reviewers also evaluated whether each task in each skill category extracted from the Army 68W training documents failed to meet, met, or exceeded those from the civilian 2019 SoPM. After each reviewer completed the evaluation of all tasks independently, disagreements were resolved, and final decisions were made by mutual agreement of extracting researchers.

Data Analysis

Descriptive statistics were calculated to describe the proportion of EMT and AEMT tasks from the civilian 2019 SoPM that are met with Army 68W SOP and training. Additionally, areas where Army 68W SOP and training are above or below civilian EMT and AEMT 2019 SoPM tasks are presented.

Results

Army 68Ws perform all 59 tasks that civilian EMTs perform based on the 2019 SoPM (Figure 2). Furthermore, Army 68Ws practice above the scope of civilian EMTs in the following skill categories: airway/ventilation (Army 68Ws perform 3 additional tasks compared to civilian EMTs); medication administration route (7 additional tasks); medical director approved medication (6 additional tasks); intravenous (IV) initiation maintenance fluids (4 additional tasks); and miscellaneous (1 additional task) (Table 1).

Figure 2. Percent of Tasks satisfied by 68W (army combat medic specialists) at the emergency medical technician (EMT) level plus any military specific task performed above the EMT level.

Table 1. Identified task by 68W (army combat medic specialists) above the civilian emergency medical technician (EMT) level.

Category	Tasks Above civilian EMT Scope of Practice
Airway	Needle chest decompression Cricothyrotomy Supraglottic airway
Cardiology	None
Splints/Stabilization	None
Medication Administration	Intradermal Intramuscular Intranasal Intravenous Subcutaneous Topical Transdermal
Director Approved Medications	Immunizations Intravenous Over-the-counter meds (oral and topical) Parental analgesia for pain Sublingual nitroglycerin for chest pain
Fluids	Intraosseous – initiation Intravenous access Intravenous initiation - peripheral Intravenous – maintenance of nonmedicated fluids
Miscellaneous	Venous blood sampling

Army 68Ws perform 96.1% (74/77) of tasks that civilian AEMTs perform based on the 2019 SoPM (Figure 3). The three tasks performed by AEMTs that Army 68Ws did not perform were tracheobronchial suctioning of an intubated patient, end-tidal carbon dioxide monitoring or waveform capnography, and inhaled nitrous oxide monitoring (Table 2). However, the Army 68W scope did include six tasks that were considered beyond the civilian 2019 SoPM for AEMTs; these tasks were in the following categories: airway/ventilation (2 additional tasks); medication administration route (2 additional tasks); and medical director approved medication (2 additional tasks).

Figure 3. Percent of Tasks satisfied by 68W (army combat medic specialists) at the advanced emergency medical technician (AEMT) level plus any military specific task performed above the AEMT level.

Table 2. Identified task by 68W (army combat medic specialists) above the civilian advanced emergency medical technician level.

Category	Tasks Below AEMT Scope of Practice	Tasks Above AEMT Scope of Practice
Airway	Tracheobronchial suctioning of an intubated patient End-tidal CO2 monitoring/waveform capnography	Needle chest decompression Cricothyrotomy
Cardiology	None	None
Splints/Stabilization	None	None
Medication Administration	None	Intradermal Topical Transdermal
Director Approved Medications	Administrating inhaled nitrous oxide	Over-the-counter medications (oral and topical)
Fluids	None	None
Miscellaneous	None	None

Full, task-level comparisons between EMT, AEMT, and Army 68Ws are available in Appendix 1.

Discussion

The primary objective of the present study was to perform a comparative analysis between the scope of practice for U.S. Army 68W Combat Medics and civilian EMTs and AEMTs. The purpose of conducting this comparison was to determine what additional training may be required to facilitate the transition of an Army 68W to a civilian EMT or AEMT. The data demonstrate a clear alignment of the 2019 SoPM for civilian EMTs and AEMTs with the SOP of Army 68W. Army 68W training covers the entirety of the civilian EMT 2019 SoPM. Slight differences existed when comparing Army 68Ws to the civilian AEMT. Army 68Ws did not perform 3 of those tasks performed by civilian AEMTs. However, Army 68Ws performed six tasks beyond the civilian AEMT. This may suggest that 68Ws could expeditiously transition to the level of civilian AEMTs. This move could benefit both the transitioning soldier and the medical community in terms of access to health care.

The civilian 2019 SoPM allows for a national-level analysis similar to those previously conducted at the state level (11–14). Previous state-based comparisons have focused on developing strategies for state licensure, which differs from national certification (15). These state-based assessments determined that Army 68Ws had the potential to be bridged to state AEMT licensure with additional education in the areas of geriatrics or the chronically ill, populations that Army 68Ws are not routinely trained to provide care (16). This study addresses the limitations of state-level licensure discussion by evaluating the agreement of Army 68W combat medics with two levels of civilian national certification, and the results demonstrate a strong potential for facilitating the transition of military members into the civilian workforce as EMTs and AEMTs, thereby strengthening the national EMS system without a significant training investment.

However, it is possible that the training investment needed may not be negligible and may require clear guidance to facilitate a robust transition plan. Since Army 68Ws often address the needs of the military workforce (predominantly 18- to 22-year-old healthy adults), additional education to support the care of a more heterogenous population may be needed. Included in this would be the care of pediatric, geriatric, and chronically ill populations, and patients who require maintenance of chronic medical devices (e.g., tracheostomy, ventilator, ventricular assist device). An important consideration is also that though classroom didactics may provide knowledge of populations evaluated in the civilian prehospital setting, this is different from the experience of managing these patients directly. Military medics do not often have exposure to a practical civilian EMS experience as part of their training. Enhanced direct patient care education may be needed to learn to independently manage the decompensating chronically ill patient. Further, the mechanism by which this is provided will also need to be considered. Whether this field training is part of an employer’s field training program or an experience provided prior to separation from the military should be determined. The exact training needs, and how these could be satisfied, will need to be defined to further facilitate civilian transitions.

Beyond the barriers to transitioning from military to civilian life common across all occupational specialties, prehospital practitioners face specific challenges in obtaining the equivalent civilian national certification and state licensure. As a result, many of the approximately 10,000 military prehospital clinicians who transition out of the military each year do not enter the civilian EMS workforce (17), for reasons including a desire to pursue non-prehospital-related medical careers, pay disparity, and no interest in civilian prehospital practice (18). Potentially driving the lack of interest in civilian prehospital practice, transitioning military EMS clinicians cite inconsistencies with their military-provided training and their corresponding civilian certification at the EMT level as a barrier to entering the civilian EMS workforce. Based on their skill set, education, and experience, these transitioning military EMS clinicians desire AEMT or even paramedic-level civilian certification upon entering a civilian career. Based on the present study’s findings, the scope of practice of Army 68Ws does potentially lend itself well to an easy transition with minimal additional training to the civilian AEMT-level certification.

Offering a pathway for these clinicians to transition to an appropriate civilian EMS level could provide employment and fulfillment to transitioning military members while strengthening the civilian EMS systems with very little training investment. Civilian EMS systems frequently rely on clinicians working overtime, leading to burnout, associated with increased sickness-related call-outs and intention to leave the profession (19). Facilitating the transition of military prehospital clinicians to an appropriate certification level of civilian prehospital care could potentially help alleviate these workforce concerns.

Limitations

This evaluation is limited in several ways. First, we focused our evaluation on the floor of Army 68W practice. We recognize that most Army 68Ws may function at a higher level based on local medical supervisor policies and needs (20). Therefore, we also noted that there might be a more favorable alignment between civilian and military scope for 68Ws functioning at higher levels. Additionally, this evaluation did not include comparisons of occupational environment and patient populations. This evaluation is also limited in the equivalence of the compared scope of practice components between Army 68W and civilian EMS clinicians, in that continuing education and physician medical credentialing of Army 68W were not explored.

Conclusion

The scope of practice of U.S. Army 68W combat medics aligns well with the civilian 2019 scope of practice model for EMTs and AEMTs. Based on the comparative scope of practice analysis, transitioning from Army 68W combat medic to civilian AEMT would require minimal additional training. This represents a potential workforce to assist with challenges in the EMS workforce. Although aligning the scope of practice is a promising first step, future research is needed to assess the relationship of Army 68Ws training with state licensure and certification equivalency to facilitate this transition.

Author Contributions

CBM, MB, and ARP conceived and designed the study. CBM, MB, JRP, JDK, and ARP analyzed the data and drafted the manuscript. All authors contributed substantially to the interpretation of the data and revision of the manuscript. CBM takes responsibility for the paper as a whole.

Institutional Clearance

This manuscript is approved by Army PAO and OPSEC for public dispersal. The views expressed are those of the author and the authors alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. government.

Previous presentation

These data were presented at the 2020 NAEMSP Annual Meeting (January 10, 2020; San Diego, CA) and the 2020 AMSUS Annual Meeting (December 6-10, 2020; Virtual).

Disclosure Statement

The authors report there are no competing interests to declare.

Appendix 1:

Scope of Practice and Skills Comparison Tables for EMT, AEMT, and 68W

Table

I. Skill – Airway/Ventilation/Oxygenation
Skill	EMT	AEMT	68W
Airway – nasal	X	X	X
Airway – oral	X	X	X
Airway – supraglottic	X	X	X
Bag-valve-mask	X	X	X
CPAP	X	X	X
Chest decompression – needle			X
Chest tube placement – assist only			X
Chest tube – monitoring and management
Cricothyrotomy			X
End-tidal CO2 monitoring and interpretation of waveform capnography		X	X
Gastric decompression – NG tube
Gastric decompression – OG tube
Head tilt – chin lift	X	X	X
Endotracheal intubation
Jaw thrust	X	X	X
Mouth-to-barrier	X	X	X
Mouth-to-mask	X	X	X
Mouth-to-mouth	X	X	X
Mouth-to-nose	X	X	X
Skill	EMT	AEMT	68W
Mouth-to-stoma	X	X	X
Airway obstruction – dislodgement by direct laryngoscopy
Airway obstruction – manual dislodgement techniques	X	X	X
Oxygen therapy – high flow nasal cannula
Oxygen therapy – humidifiers	X	X	X
Oxygen therapy – nasal cannula	X	X	X
Oxygen therapy – non-rebreather mask	X	X	X
Oxygen therapy – partial rebreather mask	X	X	X
Oxygen therapy – simple face mask	X	X	X
Oxygen therapy – Venturi mask	X	X	X
Pulse oximetry	X	X	X
Suctioning – upper airway	X	X	X
Suctioning – tracheobronchial of an intubated patient		X
II. Skill – Cardiovascular/Circulation
Skill	EMT	AEMT	68W
Cardiopulmonary resuscitation	X	X	X
Cardiac monitoring − 12 lead ECG acquisition and transmission	X	X	X
Cardiac monitoring − 12 lead electrocardiogram (interpretive)
Cardioversion – electrical
Defibrillation – automated / semiautomated	X	X	X
Defibrillation – manual
Skill	EMT	AEMT	68W
Hemorrhage control – direct pressure	X	X	X
Hemorrhage control – tourniquet	X	X	X
Hemorrhage control – wound packing	X	X	X
Transvenous cardiac pacing – monitoring and maintenance
Mechanical CPR device	X	X	X
Telemetric monitoring devices and transmission of clinical data, including video data	X	X	X
Transcutaneous pacing
III. Skill – Splinting, Spinal Motion Restriction, and Patient Restraint
Skill	EMT	AEMT	68W
Cervical collar	X	X	X
Long spine board	X	X	X
Manual cervical stabilization	X	X	X
Seated SMR	X	X	X
Extremity stabilization – manual	X	X	X
Extremity splinting	X	X	X
Splint – traction	X	X	X
Mechanical patient restraint	X	X	X
Emergency moves for endangered patients	X	X	X
IV. Skill – Medication Administration – Routes
Skill	EMT	AEMT	68W
Aerosolized/nebulized	X	X	X
Endotracheal tube
Inhaled	X	X	X
Intradermal			X
Intramuscular		X	X
Intramuscular – auto-injector	X	X	X
Intranasal		X	X
Intranasal – unit-dosed, premeasured	X	X	X
Intraosseous – initiation, pediatrics or adult		X
Intravenous		X	X
Mucosal/sublingual	X	X	X
Nasogastric
Oral	X	X	X
Rectal
Subcutaneous		X	X
Topical			X
Transdermal
V. Medical Director Approved Medications
Medications	EMT	AEMT	68W
Use of epinephrine (auto-injector) for anaphylaxis (supplied and carried by the EMS agency)	X	X	X
Use of auto-injector antidotes for chemical/hazardous material exposures	X	X	X
Use of opioid antagonist auto-injector for suspected opioid overdose	X	X	X
Medications	EMT	AEMT	68W
Immunizations		X	X
Inhaled – beta-agonist/bronchodilator and anticholinergic for dyspnea and wheezing	X	X	X
Inhaled – monitor patient administered (i.e., nitrous oxide)		X
Intranasal – opioid antagonist for suspected opioid overdose	X	X	X
Intravenous		X*	X
Maintain an infusion of blood or blood products
Oral aspirin for chest pain of suspected ischemic origin	X	X	X
Oral glucose for suspected hypoglycemia	X	X	X
OTC analgesics for pain or fever	X	X	X
OTC medications, oral and topical			X
Parenteral analgesia for pain		X	X
Sublingual nitroglycerin for chest pain of suspected ischemic origin – limited to patient’s prescribed medication	X		X
Sublingual nitroglycerin for chest pain of suspected ischemic origin		X
Thrombolytics
VI. Skill – IV Initiation/Maintenance Fluids
Skill	EMT	AEMT	68W
Access indwelling catheters and implanted central IV ports
Central line – monitoring
Intraosseous – initiation, peds or adult	X^†	X
Intravenous access		X
Intravenous initiation – peripheral		X
Skill	EMT	AEMT	68W
Intravenous – maintenance of nonmedicated IV fluids	X	X
Intravenous – maintenance of medicated IV fluids
VII. Skill – Miscellaneous
Skill	EMT	AEMT	68W
Assisted delivery (childbirth)	X	X	X
Assisted complicated delivery (childbirth)	X	X	X
Blood chemistry analysis
Blood pressure automated	X	X	X
Blood pressure – manual	X	X	X
Blood glucose monitoring	X	X	X
Eye irrigation	X	X	X
Eye irrigation –hands-free irrigation using a sterile eye irrigation device
Patient transport	X	X	X
Venous blood sampling		X	X

* Limited to analgesia, antinausea/antiemetic, dextrose, epinephrine, glucagon, naloxone, and others defined by local/state policy.

^† Adults only.

Abbreviations: EMT, emergency medical technician; AEMT, advanced emergency medical technician; 68W, army combat medic specialists; CPAP, continuous positive airway pressure; CO₂, carbon dioxide; NG, nasogastric; OG, orogastric; CPR, cardiopulmonary resuscitation; SMR, spinal motion restriction; EMS, emergency medical services; OTC, over the counter; IV, intravenous.