# The practicality of EMT Basics as an emergecy responder



## Veneficus (Aug 23, 2012)

While engaged in the endless threads here about EMTBs expanded scopes, usefulness, demands, etc, and having more time on my hands lately, I was wondering...

Is the service provided by the EMTB level really useful? (not to be confused with service provided by people who are EMTBs as like all providers there are good ones and bad ones)

In standard dinosaur manner, when I became an EMT-B, it was likely that was all anyone who called 911 was getting. We were the primary responders as well as the only prehospital person anyone was likely to see. From Soup to nuts, we ran every aspect of the call. 

It seemed to work really well. (For what we knew at the time)

As paramedics became more popular in the area, the EMT was largely relegated to carrying equipment, driving, and performing ordered tasks in the official role as "a borrowed servant."

In this role, all of the benefits of being an EMT before becomming a medic are largely lost.

As our knowledge and technology advanced, the "basic" levels of assessment and intervention have largely become obsolete. 

Yet the curriculum still revolves around EMTs being the sole responder in charge. (No doubt in many places they are still)

But for all of the advancement in scope and education, the level of assessment is still woefully under what is required. Evidenced by the stressing of calling for ALS throughout the educational process. 

It is generally accepted in medicine, including prehospital, patients should be treated for pain. 

It is a medical error to over-treat patients. (though we must admit to accepting some level of over treatment in any acute environment.)

But what do basics bring to the table?

CPR and an AED?
We know that early CPR and defib are effective treatments. But we also know that it is the bystander who will be able to effect this in time. CPR and an AED are useless after 8 minutes of nothing.

Assisting with meds? 
Anyone can assist with meds. It doesn't even take a responder.

A handful of meds already carried and utilized by more advanced providers?

A spint?

A backboard?

I think it is obvious that many basics realize or want more treatments to be more effective. From narcan to pain medication. 

There are dozens of add on certs in various states to amplify the value of the Basic EMT. 

Nothing taught in EMT class is really useful for IFT, where most EMT Basics work. 

In an ALS system, the Basic is far more useful as the tech for the medic than an independant provider. 

Perhaps we should just come to terms that with the levels of medical care and technology expected today, the solution is not to "upskill" or "up educate" the EMT Basic. 

The solution may be to just get rid of it?

The recently revamped AEMT is basically the minimum skill set and knowledge base that incorperates all of the "upskills" and add on meds Basics seem to think they need.

Should AEMT be the minimum to work on a EMS transport unit?

With the Basic level being the minimum level of "first responder."

Even at 150 hours for EMT, it is reasonable to do away with the first responder level entirely.


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## MrJones (Aug 23, 2012)

On the other hand, there are those here who would argue that one must spend time as a practicing EMT-B prior to starting medic training in order to be a competent and effective medic.

:huh:


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## Veneficus (Aug 23, 2012)

firstshirt said:


> On the other hand, there are those here who would argue that one must spend time as a practicing EMT-B prior to starting medic training in order to be a competent and effective medic.
> 
> :huh:



I have already utterly dispelled that nonsense so completely, I will not do it again here. Not only from the standpoint of an educator but also from going that route myself.


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## NYMedic828 (Aug 23, 2012)

firstshirt said:


> On the other hand, there are those here who would argue that one must spend time as a practicing EMT-B prior to starting medic training in order to be a competent and effective medic.
> 
> :huh:



Just as you must spend time as a practicing RN/PA to become an MD? O wait... You don't...-_-

My EMT class was out learned in under 2 initial weeks of my medic program. My EMT class was an absolute was of time.


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## MrJones (Aug 23, 2012)

Veneficus said:


> I have already utterly dispelled that nonsense so completely, I will not do it again here. Not only from the standpoint of an educator but also from going that route myself.



Maybe so, but there are still those who have not seen the light. I'm on your side of the argument, btw*, but felt it appropriate to acknowledge the opposing POV.



* I'm currently in a paramedic program that starts w/ EMTB certification and continues up through EMTP certification with just the usual clinicals/ride time found in any paramedic program and no requirement to work as an EMT outside of the program. I may start my ride time a bit behind the power curve in comparison to an EMTB who has been on the street for a while, but I view that as a minor issue that will self-correct in short order.


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## Medic Tim (Aug 23, 2012)

Vene that is pretty much what happens here. The first responder is a 200 or so hour course that is about the same as emt b in the us. Ourfirst level of Medic is about the AEMT and our advanced medic is close to the us paramedic . On the east coast most all ambulances (all of them) are staffed by paramedics. First responders are rarely used or used in very rural areas. As I have said in other posts similar to this topic ...... People here become paramedics to be paramedics, it is not a stepping stone to rn or whatever. To be a pcp or primary care Medic it is 9 months to 2 years depending on the province. Advanced care medics have an additional 1 to 2 years of education and usually requires at least a few years as a pcp to even be considered. It is also very expensive to go to Medic school. The higher educational standards, time commitment, and financial commitment usually weed out a lot of people.


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## medicdan (Aug 23, 2012)

Maybe the more important question is whether the mere transport is more important than the field assessment and basic treatment. I'd argue that in _some _ cases, the transport is the beneficial intervention for the patient, not the field assessment and field treatment.


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## Veneficus (Aug 23, 2012)

Medic Tim said:


> Vene that is pretty much ebay happens here. The first responder is a 200 or so hour course that is about the same as emt b in the us. Ourfirst legs of Medic is about the AEMT and our advanced medic is close toy the us paramedic . On the east coast most all ambulances (all of them) are staffed by paramedics. First respondersare rarely used or used in very rural areas. As I have said in other posts similar to this topic ...... People here become paramedics to be paramedics, it is not a stepping stone to rn or whatever. To be a pcp or primary care Medic it is 9 months to 2 years depending on the province. Advanced care medics have an additional 1 to 2 years of education and usually requires at least a few years as a pcp to even be considered. It is also very expensive to go to Medic school. The higher educational standards, time commitment, and financial commitment usually weed out a lot of people.



I am not talking about weeding people out.

I am just wondering if we need to simply ackowledge that the Basic level is just not going to meet the needs or expectations anymore.

There was a time when surgeons didn't go to medical school. But as knowledge and medicine advanced, it became needed for them to.


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## Medic Tim (Aug 23, 2012)

Veneficus said:


> I am not talking about weeding people out.
> 
> I am just wondering if we need to simply ackowledge that the Basic level is just not going to meet the needs or expectations anymore.
> 
> There was a time when surgeons didn't go to medical school. But as knowledge and medicine advanced, it became needed for them to.



I understand 

I did not intend to stress the weeding out part. With fewer providers there will be more demand. There will be better work conditions and better wages. Higher education is the key to it all. I am sorry if I am taking this in a different direction than you intended but I believe it does play a role.

If it were up to me the AEMT would be the minimum staffing for an ambulance and Paramedics would have degrees.

The traditional, take everyone to the ER needs to go away. Code 3 or running hot to and from everything needs to go away. It puts everyone on the road at risk and all because someone panicked over something benign. Providers need to be able to use common sense and clinical judgement to treat the pt they have in front of them. A few hundred hours is no where near enough. The current medic level is not enough though that is for another thread.


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## Jambi (Aug 23, 2012)

Medic Tim beat me to it.  I was going to suggest a comparison to Canada/UK/NZ "Basics." 

How and to what level are they trained, and what is their scope (for lack of a better term).

Contrast that to EMR and EMT.  I don't have the knowledge to do a good comparison outside of knowing that our northern cousins receive longer (better) training and operate with greater responsibility that do our American Basics.

I'm with Vene here.  Our entry level is far too elementary.  Any change to this is/will be opposed by large fire organizations that want their firefighters "trained" with the least amount of time and money involved so they can say, "Look! We have paramedics too! We're trained too!" <_<

American AEMT should be entry level and require actual academic education as part of it.

If I could get my basic students to have English, Math, Basic A&P, Intro Chem and a Psych or Sociology class, much of our "basic academic skills" problems would go away.


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## Veneficus (Aug 23, 2012)

I don't think it is just a question of training and education.

That has been hashed out before.

What I am wondering is if the demands of today have basically made the basic level pointless.


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## bahnrokt (Aug 23, 2012)

Before I got into EMS I was under the impression that the point of an ambulance is to rapidly transport a sick or injured person to a hospital.  That was the main goal of an ambulance 30-40 years ago before we started to move the ER into the field.  
The vast majority of PTs that medics touch these days are not that critical. Most of them could be transported BLS with no difference in outcome.  Getting a line in now vs in 15 min when they are in the ER, it doesn't really have a big effect on long term outcome for a lot of PTs.  

To me it comes down to is it better to load the pt and run hot to the ER or to wait 10-20min while a medic ****ers around with an IV, some drugs, monitor, etc and then leave.  I know the best answer is for the medic to work while the rig drives, but most of the medics in my system hate to work in a moveing vehicle. 

I think the point I am moveing toward is that most patients will do just fine with a qualified BLS crew.


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## Jambi (Aug 23, 2012)

Veneficus said:


> What I am wondering is if the demands of today have basically made the basic level pointless.




*Yes it is*, except for those places that would otherwise have nothing. Even then, the additional training from Basic-AEMT is negligible and should be skipped.


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## Medic Tim (Aug 23, 2012)

bahnrokt said:


> Before I got into EMS I was under the impression that the point of an ambulance is to rapidly transport a sick or injured person to a hospital.  That was the main goal of an ambulance 30-40 years ago before we started to move the ER into the field.
> The vast majority of PTs that medics touch these days are not that critical. Most of them could be transported BLS with no difference in outcome.  Getting a line in now vs in 15 min when they are in the ER, it doesn't really have a big effect on long term outcome for a lot of PTs.
> 
> To me it comes down to is it better to load the pt and run hot to the ER or to wait 10-20min while a medic ****ers around with an IV, some drugs, monitor, etc and then leave.  I know the best answer is for the medic to work while the rig drives, but most of the medics in my system hate to work in a moveing vehicle.
> ...



Most of those pt's you are talking about do not need the ER. A consult or a family md visit or an urgent care center are usually what a pt needs.

I rarely ever go LS to the hospital. Besides the fact it isn't safe you do not save time, you increase the pt's anxiety and most people are horrible at driving code. You can go on and on. A smooth ride is better than a fast ride.


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## NYMedic828 (Aug 23, 2012)

At this point in the US there is simply too many EMTs to be able to come to a simple solution to the problem.

In my opinion, the only way to fix EMS, is to let it fall, and rebuild from the ground up.


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## nocoderob (Aug 23, 2012)

The "B" training is _too_ basic. And the class is easy thus the reason there are _so_ many. It seem's backward's but, I'd like to see an advanced type of emt. We used to have EMT II (which was eliminated in favor of "P") which had limited als capability. That way a basic would do IFT and the advanced would work alongside the paramedic. That would be a much more harmoniou's team as they are similar but, the medic would be the team leader with the "A" not far behind. (Think doctor and RN as opposed to doctor and CNA) The disparity of training and ability between a basic and medic is too extreme.

Quoted from Medic Tim:
_The traditional, take everyone to the ER needs to go away. Code 3 or running hot to and from everything needs to go away._

Absolutely. Not everyone needs a ride to the ED, which is opposed by most companie's as transport's mean potential dollar's. There is no reason we could not arrive, assess, and recommend other mean's of transport. SF EMS can do it but, they are run by the city which could be the reason why they can.
Code 3 to most calls needs to go away also. We get code 2 response's to old lady's that have fallen with broken bone's and code 3 to 22 year old's with abd pain all the time.


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## mycrofft (Aug 23, 2012)

http://www.emtlife.com/showthread.php?t=30919
Jambi Quote: Yes it is, except for those places that would otherwise have nothing. Even then, the additional training from Basic-AEMT is negligible and should be skipped.
*Agreed.* 
bahnrokt Quote:  To me it comes down to is it better to load the pt and run hot to the ER or to wait 10-20min while a medic ****ers around with an IV, some drugs, monitor, etc and then leave. I know the best answer is for the medic to work while the rig drives, but most of the medics in my system hate to work in a moveing vehicle. 

I think the point I am moveing toward is that most patients will do just fine with a qualified BLS crew.
*Agreed.*

We keep making sweeping generalizations based reactively to one or another paradigm, and those are either an *urban heart attack*, or a *rural motor vehicle accident* (the latter being the one for which EMT A's and P's were invented by DOT). Then the governments, EMS employers, and eager practitioners who don't want to go to the expense and trouble to upgrade their training from Basic to Paramedic, or Paramedic to another technician/PA/FNP or MD/DO started creating all these hyphenated basic EMT's, which muddles the issues of interstate accreditation for hiring, standardization, funding, and accountability. Also fragments the prehospital EMS practitioners with an ersatz internal hierarchy.

With infinite money and suitable candidates, we can do both paradigms and everything in between, but more and more evidence-based science and monetary realities force us to start thinking about practicalities. Yet we *don't*. We want EMT-B's to start IV's, we don't want to attend the prerequisite trainings but still give drugs (necessitating protocols/standing orders decried as "cookbooks"). 

As has been established after first aid, with urban gunshot wounds (hospital/blood/diagnostics/surgery); and CVA's (hospital/diagnostics/surgery or TPA); and MI's ("chain of survival" ends with hospital/diagnostics/surgery or other technique, or discharge), yes, _you do have to get the pt in promptly_. In rural/frontier areas, the important but not definitive early treatments require widespread practitioners which the economies and populations won't support much higher than EMT-B or First Responder. The interfacility transfers even in urban settings often prudently require someone able and willing to do something besides wring their hands and drive faster, which sounds like a driving infraction, but so be it.

Just decide where the floor needs to be (basic , paramedic, or some mutant in between),establish training and certification, clean out the other horsehocky categories, and quit screwing around.

PS:Quoted from Medic Tim:The traditional, take everyone to the ER needs to go away. Code 3 or running hot to and from everything needs to go away.
True, but then you need field practitioners far better qualified than a Basic.

There are many cases where something which appears innocuous is the (sometimes imminent) precursor to something ruinous; the excuse "My training didn't cover that" won't cut it. Although MOST calls are not requiring of EMT transport, they need someone with much more diagnostic training and experience than a Basic (or hyphenated-Basic, Advanced Whoopeedoo or whatever) will have. Not talking Andromeda Strain or "House MD"'s "paraneoplastic syndrome", we're talking CVA's, infections, aortic aneurysms, sexually transmitted diseases, early dementia, mishaps of pregnancies, and basic psychiatric/psychological crises, to name just a few.

PPS: here's a thought. Instead of spreading EMT's around and trying to bring the hospital to the doorstep, why not reverse the trend and make more urgent and non-ER care available in a more-disseminated fashion, using modern technology and telemedicine to allow the (re)creation of....community hospitals? Doctor's offices?


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## Schroeder (Aug 23, 2012)

In my (very limited) experience, the system works quite well. I see EMT-B's as the gate keepers. Getting there first, making the Sick/Not Sick decision is very important. We keep the resources allocated where they are needed most. Then again that goes back to the whole dual Medic vs Medic/Basic argument.

If the patient really needs more than BLS, even a little bit, they're more than likely going to need a Medic anyway. The rest of what we see can easily be handled by Basics. We don't use EMT-I's here for that reason.


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## nocoderob (Aug 23, 2012)

Schroeder said:


> In my (very limited) experience, the system works quite well. I see EMT-B's as the gate keepers. Getting there first, making the Sick/Not Sick decision is very important. We keep the resources allocated where they are needed most. Then again that goes back to the whole dual Medic vs Medic/Basic argument.
> 
> If the patient really needs more than BLS, even a little bit, they're more than likely going to need a Medic anyway. The rest of what we see can easily be handled by Basics. We don't use EMT-I's here for that reason.



I find this system odd. Shouldn't the medic do the assessment and triage down to BLS if that is what is needed?


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## Schroeder (Aug 23, 2012)

What do you see that is odd about it?

Unless there are certain indicators in the 911 call, BLS is dispatched. We arrive, and make our Sick/Not sick call based on our protocols, MOI, NOI etc. This way, BLS providers get very good at handling "not sick" patients, and ALS only handle "sick" patients. We have adequate tools to handle sick patients until Medics arrive.

The resources are allocated appropriately, and you usually get a response from someone who has lots of experience doing what they do.

Maybe I'm misunderstanding what you're asking?


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## Veneficus (Aug 23, 2012)

Schroeder said:


> We arrive, and make our Sick/Not sick call based on our protocols, MOI, NOI etc. This way, BLS providers get very good at handling "not sick" patients, and ALS only handle "sick" patients.



I do not think this is an accurate assessment.

I don't think Basics have any idea what is sick or not sick unless it is so obvious anyone could figure it out or they had a specific experience in that particular presentation before. 

I think triage based on things like MOI are extremely unreliable and cause more than a reasonable level of over-triage compared to what can be attained with current ALS providers. 

Over-triage means wasted resources based on "just in case."

Consider what constitutes an emergency patient?

a. a patient who has an acute life threatening condition requiring immediate intervention.

b. a patient who if doesn't receive prompt intervention will deteriorate to a. 

Undoubtably Basics have the ability to make a difference in a. 

But b. is becomming more common in western society.


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## Schroeder (Aug 23, 2012)

This may be true. I don't claim to have lots of experience telling me otherwise. This is, however, what I was trained to do. And of what I have seen, It works well.

You could give basics some benefit of the doubt when determining "sick" patients however. At least in my protocols, I have very clearly outlined ALS indicators which have been drilled into me from day one.


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## Veneficus (Aug 23, 2012)

Schroeder said:


> You could give basics some benefit of the doubt when determining "sick" patients however. At least in my protocols, I have very clearly outlined ALS indicators which have been drilled into me from day one.



I understand your position to be: you know what sick is because if you don't know you call ALS, thus categorizing the patient as "sick?"


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## Schroeder (Aug 23, 2012)

Just to make sure I'm being clear:
In my system, "Sick" is defined as any patient who needs ALS. Not sick is any patient that can be handled by BLS. 

Maybe I'm thinking of something different that what you are referring to?


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## Jambi (Aug 23, 2012)

Schroeder said:


> Just to make sure I'm being clear:
> In my system, "Sick" is defined as any patient who needs ALS. Not sick is any patient that can be handled by BLS.
> 
> Maybe I'm thinking of something different that what you are referring to?



The point is that your average EMT-like-mammal does not posses the education, training, experience, or ability to accurately determine sick or not sick outside of those obvious conditions that anyone can recognize.


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## Veneficus (Aug 23, 2012)

Schroeder said:


> Just to make sure I'm being clear:
> In my system, "Sick" is defined as any patient who needs ALS. Not sick is any patient that can be handled by BLS.
> 
> Maybe I'm thinking of something different that what you are referring to?



I used the common medical definition of sick. Defined above.


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## Schroeder (Aug 23, 2012)

Alright then. You'll have to excuse my persistence. My point of view is that of a Basic, so the information I get is interpreted as such. 

What kinds of factors are you referring to that Basics couldn't catch?


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## nocoderob (Aug 23, 2012)

Schroeder said:


> What do you see that is odd about it?
> 
> Unless there are certain indicators in the 911 call, BLS is dispatched. We arrive, and make our Sick/Not sick call based on our protocols, MOI, NOI etc. This way, BLS providers get very good at handling "not sick" patients, and ALS only handle "sick" patients. We have adequate tools to handle sick patients until Medics arrive.
> 
> ...



Let me be more clear. If ALS shows up and the "arm cramp" complaint actually turns out to be cardiac, the medics are there and do their thing. If BLS was dispatched, the pt now has to wait longer for the ALS rig to arrive. The answer from many basics will then be just to haul azz to the ED and not wait for ALS. I see this as a disservice to the pt.


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## Schroeder (Aug 23, 2012)

Our protocols have us wait or intercept with Medics. Since we're in an urban center, the wait time in only a few minutes.


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## nocoderob (Aug 23, 2012)

Schroeder said:


> Our protocols have us wait or intercept with Medics. Since we're in an urban center, the wait time in only a few minutes.



The point I am trying to make is why should the pt have to wait longer? This job is filled with "minutes." From response times, scene times, 911 to balloon times, and on and on. To say "only a few minutes more" is really a cop out by the system.


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## Veneficus (Aug 23, 2012)

nocoderob said:


> The point I am trying to make is why should the pt have to wait longer? This job is filled with "minutes." From response times, scene times, 911 to balloon times, and on and on. To say "only a few minutes more" is really a cop out by the system.



How often do minutes really make a difference?


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## nocoderob (Aug 23, 2012)

Veneficus said:


> How often do minutes really make a difference?



Depends on how many minutes you are talking. I guess I wouldn't be happy to have a family member in a potentially lethal rythym sitting with the emt's
while waiting for als that, in my opinion of course, should have been dispatched initially.


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## Veneficus (Aug 23, 2012)

nocoderob said:


> Depends on how many minutes you are talking. I guess I wouldn't be happy to have a family member in a potentially lethal rythym sitting with the emt's
> while waiting for als that, in my opinion of course, should have been dispatched initially.



How would you know what the rythym is?


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## nocoderob (Aug 23, 2012)

Veneficus said:


> How would you know what the rythym is?



Thats my point. The emt's _wouldn't_ know.


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## mycrofft (Aug 23, 2012)

We ran a tired (make that "tiered") system of sorts at my work. RN's did sick call, and if what we saw fell into parameters needing emergency care or to see the MD (now, soon, or later as scheduled), we did it; otherwise, we had "standardized procedures" (an inch and a half thick).

BUT we were not EMT's. Good part: we (putatively) had better education as to diagnostics of simple primary care, emergencies, and malingering. Bad part: since they had little to no practical emergency education, many of my cohorts just turfed everything except the easiest calls to the MD. Occasionally they failed to and then I had to run emergently on them.

I think there are some very basic diagnostics EMT-B ought to be able to do (fingerstick glucometry, pulse oximetry, otoscopy of the external nares and the ear, taking a temperature orally or rectally) which are not infrequently taught to family members, and could provide more info for triage. I now, this is against my general stance (stop inflating ratings), but these are so simple.


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## mycrofft (Aug 23, 2012)

This thread makes me want more than ever to have a means of separating discussions by geopolitics (urban/suburban, rural, remote (frontier, oil rigs, expeditions, New Zealand extreme eco ironman triathlons, etc),


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## Bullets (Aug 23, 2012)

mycrofft said:


> This thread makes me want more than ever to have a means of separating discussions by geopolitics (urban/suburban, rural, remote (frontier, oil rigs, expeditions, New Zealand extreme eco ironman triathlons, etc),



Absolutley, because we have the discussions and they always turn into "Well in Big City EMS we do it this way" and "In Ruralburg EMS we do it this way" and "Middle of Antartica EMS we do things like this"

and we realize that what works for a high populated state like NJ doesnt for Montana or the Dakotas. 

This is the problem that currently exists, if a patient says "I wanna go"  then we go and we cant refuse the transport. And i love the idea of a community paramedicine but so far we havent seen American medics do this with any form of consistency.

Whats the science and studies so far? More medics = bad medics. Response time doesnt matter, ACLS might just be junk, oxygen has been over applied, we dont treat pain appropriatley

The system needs to be stripped down and reevaluated. What works? Compressions, electricity, direct pressure, D50 ect... What doesnt work? Throw it out!  The decide if we want a two tier or one tier system and break the skills up accordingly. 

And then use the choppers for something that actually matter, put Docs in them and fly em to scenes, instead of just generating a big bill and letting people yell "SEND THE BIRD" on the radio


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## leoemt (Aug 23, 2012)

Veneficus said:


> While engaged in the endless threads here about EMTBs expanded scopes, usefulness, demands, etc, and having more time on my hands lately, I was wondering...
> 
> Is the service provided by the EMTB level really useful? (not to be confused with service provided by people who are EMTBs as like all providers there are good ones and bad ones)
> 
> ...



I would say it depends on area and what is expected. Here in my area, I don't see Medics performing "Basic" Skills. The EMT's thump the chest during CPR, perform extrication and stabilization. Medics busy themselves with the ALS stuff. Drugs, advanced airways, 12 leads, etc. 

It is also dependent on local protocols. In my county I have to obtain my IV and Combitube endorsements as a Basic. 

Lets face it, Paramedics have a tremendous wealth of knowledge and abilities and are a vital role to emergency service. Despite that, Basic skills save lives. Drugs, and advanced airways, etc. can have a significant impact on patient outcomes - but without good basic skills its all a moot point. It is easier and cheaper to train a basic to perform basic skills than it is to train everyone to the level of ALS. 

Basic's will never go away. Just like the First Responder has never gone away (though it is not always recognized by every area). 

My personal opinion is we should have a Medic - Basic and a Medic - Advanced (the public refers to us as Medics anyways, make it easy for them). The basic should have the training of what is now an Advanced EMT and the Advanced should have the training of what is now the Paramedic and maybe even then some. Maybe closer to an RN. 

I am sure in other areas Paramedics do more basic and advanced skills. In my area it would be a rare event to see Paramedics doing BLS skills but that is just how were set up.


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## DrParasite (Aug 23, 2012)

Bullets said:


> Whats the science and studies so far? More medics = bad medics. Response time doesnt matter, ACLS might just be junk, oxygen has been over applied, we dont treat pain appropriatley
> 
> The system needs to be stripped down and reevaluated. What works? Compressions, electricity, direct pressure, D50 ect... What doesnt work? Throw it out!  The decide if we want a two tier or one tier system and break the skills up accordingly.


Well said.


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## Brandon O (Aug 23, 2012)

I find it peculiar that you'd say, Vene: "As our knowledge and technology advanced, the 'basic' levels of assessment and intervention have largely become obsolete" -- given your belief in and advocacy for the traditional clinical H&P.

Which, strictly speaking, is within the BLS scope of practice.


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## mycrofft (Aug 24, 2012)

A true H&P, not the stripped down version, is not taught to BLS personnel. That is the root of so many incidents, one does not know _wha_t one does not know unless someone else tells you, or you drive a patient right over the cliff then have to figure out why things went west, maybe at a coroner's inquest or a Grand Jury.


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## EpiEMS (Aug 24, 2012)

Wouldn't teaching a complete version of H&P to BLS providers require a background in biology and chemistry?


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## mycrofft (Aug 24, 2012)

No, although it wouldn't hurt. Anatomy and Physiology and Physical Exam are needed, plus some special work in recognition of common and uncommon complaints...such as a year working in a primary care or family practice clinic with a bunch of shifts in an ED. A week or two in Ortho, Cardio, Pulmo, etc would not be amiss either.


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## Brandon O (Aug 24, 2012)

mycrofft said:


> A true H&P, not the stripped down version, is not taught to BLS personnel.



I agree that it is often not taught. But strictly speaking, that doesn't mean it's not BLS. To me, BLS involves the fundamentals of assessment, diagnosis, decision-making, and life support. They're essential at all levels of care and we should all strive to master them. With that attitude, ALS becomes BLS plus more interventions and some additional diagnostics. I think these can be useful for palliation (if they're actually used), useful or even essential for patient management in rare to very rare cases, and in certain situations (i.e. early STEMI detection and diversion/activation) beneficial to course of care. But just as often they stand in the way of the BLS that ought to be happening.

In most emergencies that I can imagine myself dialing three digits for, I'd want someone to show up who will do extremely good BLS, perhaps with some pain management or other palliative care on top. I don't care what their initialism is.


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## Brandon O (Aug 24, 2012)

EpiEMS said:


> Wouldn't teaching a complete version of H&P to BLS providers require a background in biology and chemistry?



Well, I'm not sure what "complete" would be; most docs spend a lifetime learning it. I suppose my point is just that, although I recognize the practicalities, I'm saddened when I see that we need to invoke ALS units just to get competent clinical assessment. That's BLS, and should be bread and butter for all of us; we should all be drinking the same water and reading from the same graven stones. Then some of us should go away and learn additional useful psychomotor skills to be paramedics.

But that's just me.


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## mycrofft (Aug 24, 2012)

"I agree that it is often not taught."
I'd say it is never taught to BLS. I spent a semester each in A,P and PEx, and none concurrent.


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## Undaedalus (Aug 24, 2012)

If the topic is whether the buck EMTB as it exists today is still a relevant provider, my response would have to be in the negative.  There is just not enough of a rigorous didactic component to Basic education to allow much clinical evaluation beyond: not breathing equals bad.  This issue, in my opinion, can be ameliorated by a more comprehensive and fundamental education with an accordantly increased scope to these providers. 

If the question is whether there is a need for providers certified below the paramedic level, then I would have to argue in the affirmative, though I'm not sure anyone here is arguing this point..  There absolutely exist arguments against skill dilution, and the cost-efficacy of high level care in remote areas that necessitate a lower level of certification below that of the paramedic.  Personally, I think a more skilled Basic provider would make mixed rigs more effective and increase the usefulness of BLS ambulances beyond the status they hold today.

Not to beat a dead horse here, but, the reason the Basic is going the way of the dodo is that even  though it's BLS skills that form the foundations of ALS care, the education needed to properly and prudently apply them is lacking.  Educating the first tier beyond near-mandatory O2 administration, and fear-based long spine boarding, as examples, is the first step towards more relevant and efficient EMS systems in the US.  Furthermore, (_in my opinion!_) the bare bones EMTB is the biggest drag on EMS salaries out there.  As long as there are undereducated and underskilled Basics hiding under every rock, whose primary role in the field is to determine whether or not they need to summon someone else, pay will remain low.


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## Veneficus (Aug 24, 2012)

Brandon Oto said:


> I find it peculiar that you'd say, Vene: "As our knowledge and technology advanced, the 'basic' levels of assessment and intervention have largely become obsolete" -- given your belief in and advocacy for the traditional clinical H&P.
> 
> Which, strictly speaking, is within the BLS scope of practice.



Within scope, yes.

Commonly taught or practiced?

No.

How many basics really listen to heart tones?

How many actually perform superficial and deep palpation of the abd.?

How about take a temperature?

Yes, I advocate history and physical, but if has to actually be done to be useful.

Look at the amount of posts in this thread referring to "in my protocol."


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## Brandon O (Aug 24, 2012)

Undaedalus said:


> If the topic is whether the buck EMTB as it exists today is still a relevant provider, my response would have to be in the negative.  There is just not enough of a rigorous didactic component to Basic education to allow much clinical evaluation beyond: not breathing equals bad.  This issue, in my opinion, can be ameliorated by a more comprehensive and fundamental education with an accordantly increased scope to these providers.
> 
> If the question is whether there is a need for providers certified below the paramedic level, then I would have to argue in the affirmative, though I'm not sure anyone here is arguing this point..  There absolutely exist arguments against skill dilution, and the cost-efficacy of high level care in remote areas that necessitate a lower level of certification below that of the paramedic.  Personally, I think a more skilled Basic provider would make mixed rigs more effective and increase the usefulness of BLS ambulances beyond the status they hold today.
> 
> Not to beat a dead horse here, but, the reason the Basic is going the way of the dodo is that even  though it's BLS skills that form the foundations of ALS care, the education needed to properly and prudently apply them is lacking.  Educating the first tier beyond near-mandatory O2 administration, and fear-based long spine boarding, as examples, is the first step towards more relevant and efficient EMS systems in the US.  Furthermore, (_in my opinion!_) the bare bones EMTB is the biggest drag on EMS salaries out there.  As long as there are undereducated and underskilled Basics hiding under every rock, whose primary role in the field is to determine whether or not they need to summon someone else, pay will remain low.



Very well said.


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## EpiEMS (Aug 24, 2012)

Veneficus said:


> Within scope, yes.
> 
> Commonly taught or practiced?
> 
> ...



Maybe the protocol-type arrangement is the problem. If everybody in EMS operated under independent licenses like in progressive systems (Canada, Australia, UK, etc.), we could avoid this -- the "College of Paramedics of the United States," say, would be able to come up with scope and such.


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## emtevan (Sep 22, 2012)

ive had many discussions about this and i dont care what people say emt-b's are very helpful and DO save lives.ive saved many and helped many people.Most calls are BLS anyways and it only becomes ALS because they put ekg's on people and give iv's.it's all how u use it and how good u are.Basics are just as good.


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## VFlutter (Sep 22, 2012)

emtevan said:


> ive had many discussions about this and i dont care what people say emt-b's are very helpful and DO save lives.ive saved many and helped many people.Most calls are BLS anyways and it only becomes ALS because they put ekg's on people and give iv's.it's all how u use it and how good u are.Basics are just as good.



:rofl::rofl::rofl:


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## RocketMedic (Sep 22, 2012)

emtevan said:


> ive had many discussions about this and i dont care what people say emt-b's are very helpful and DO save lives.ive saved many and helped many people.Most calls are BLS anyways and it only becomes ALS because they put ekg's on people and give iv's.it's all how u use it and how good u are.Basics are just as good.



What is the BLS fix for anaphylaxis? What about something like a near-total airway obstruction resistant to the Heimlich? What about seizures? What about pain relief or nausea?

Still, attitudes like this are (I think) the product of a UK-like system where the scopes of practice between paramedics and EMTs are narrowed.


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## abckidsmom (Sep 22, 2012)

Rocketmedic40 said:


> What is the BLS fix for anaphylaxis? What about something like a near-total airway obstruction resistant to the Heimlich? What about seizures? What about pain relief or nausea?
> 
> Still, attitudes like this are (I think) the product of a UK-like system where the scopes of practice between paramedics and EMTs are narrowed.



In my experience, attitudes like this are results of EMT instructors with unreasonable views of BLS care who spend the whole entire 100 hours telling the people what lifesavers they are about to become instead of telling them that they are firmly and officially at the jumping off point.


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## RocketMedic (Sep 22, 2012)

EpiEMS said:


> Maybe the protocol-type arrangement is the problem. If everybody in EMS operated under independent licenses like in progressive systems (Canada, Australia, UK, etc.), we could avoid this -- the "College of Paramedics of the United States," say, would be able to come up with scope and such.



Then again, look at the differences in a UK paramedic to a US paramedic to a Canadian or AUS/NZ medic. Everything I've ever heard about UK medics is that they are closer in scope of practice to American EMT-I/85 or a military medic with less emphasis on cardiology and pain palliation than American medics. 

AUS/CAN/NZ medics are, in my opinion, where American paramedics should push our education base and scope of practice to. 

In my opinion, a 2-year associate's degree with EMT-Advanced should replace EMT-Basics entirely (yes, even in rural areas), with a 4-year Bachelor's equivalent for Paramedics.

This, of course, would predicate a significant wage increase for EMS in general and Paramedics in particular.


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## RocketMedic (Sep 22, 2012)

abckidsmom said:


> In my experience, attitudes like this are results of EMT instructors with unreasonable views of BLS care who spend the whole entire 100 hours telling the people what lifesavers they are about to become instead of telling them that they are firmly and officially at the jumping off point.



Many of those are medic mills who are financially vested in delusions and "education", not real education. See the watered-down card courses, OSHA/JHACO-mandated "everyone certifies" and EMT-B as textbook results.


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## Bullets (Sep 22, 2012)

Rocketmedic40 said:


> What is the BLS fix for anaphylaxis? What about something like a near-total airway obstruction resistant to the Heimlich? What about seizures? What about pain relief or nausea?
> 
> Still, attitudes like this are (I think) the product of a UK-like system where the scopes of practice between paramedics and EMTs are narrowed.



Whats the ALS fix for Stroke? Cadiac Arrest? Bleeding?


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## RocketMedic (Sep 22, 2012)

Bullets said:


> Whats the ALS fix for Stroke? Cadiac Arrest? Bleeding?



Rapid transport to a facility with true definitive care, not "community hospital X".

Definitive care for cardiac arrest is changing every day, but I'd bet it ends up being ALS and BLS combined with insane amounts of luck.


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## abckidsmom (Sep 22, 2012)

Bullets said:


> Whats the ALS fix for Stroke? Cadiac Arrest? Bleeding?




ACLS, airway management, treatment of hypoglycemia if indicated
ACLS, post-resuscitation care as needed
control bleeding, monitoring for complications, tourniquet placement if needed

There are no fixes, but there are plenty of things on the to-do list.  Also, I find that the hospital takes informed pre-alerts more seriously.  How many BLS providers do you know who've transported an MI straight to the cath lab, or a CVA right to the CT scanner?


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## VFlutter (Sep 22, 2012)

Bullets said:


> Whats the ALS fix for Stroke? Cadiac Arrest? Bleeding?



Stroke is really the only one of the three that you can argue there is no prehospital treatment (let's just say bleeds not clots). But the presence of situations in which there is no meaningful treatment is not an argument for the value of EMT Basics. There are a lot more common situations in which basics are worthless than there are situations in which paramedics can do nothing. I don't really see your arguememt?


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## Medic Tim (Sep 22, 2012)

Bullets said:


> Whats the ALS fix for Stroke? Cadiac Arrest? Bleeding?



I wouldn't call them a "fix" but.
Some areas have prehospital fibrinolytics they can also check and treat hypoglycemia as needed.

 medics have access to acls drugs though the benefit of them has and is questionable. 

Some places have topical hemostatic agents and I know of one area that has tranexamic acid for traumatic hemorrhage.


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## Bob67 (Sep 22, 2012)

I think the level of care has to match the need. Yes it is much easier said then done. It also depends on your location and how quickly you can get the next level of care. 

Do you think the insurance companies want to pay medics for a lift assist?


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## Veneficus (Sep 22, 2012)

Bob67 said:


> Do you think the insurance companies want to pay medics for a lift assist?



Do you think insurance companies want to pay for anything at all?


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## VFlutter (Sep 22, 2012)

Bob67 said:


> Do you think the insurance companies want to pay medics for a lift assist?



Call the fire department. You do not need medical training for a lift assist.


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## abckidsmom (Sep 22, 2012)

ChaseZ33 said:


> Call the fire department. You do not need medical training for a lift assist.



In our area, those are high-risk calls.  Old people who "don't want to bother" us call for help getting up after their syncopal episode, hip fx, etc.  At least half of them are actually sick, and need to go to the hospital.


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## Bob67 (Sep 22, 2012)

ChaseZ33 said:


> Call the fire department. You do not need medical training for a lift assist.



But, you don't know what they will turn into. Some turn into ALS calls and some require several assists and a bariatric truck. 

I am looking at it from a resource allocation perspective. The first responders may also be overwhelmed or feel under utilized if they feel the calls are above or below them.


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## NYMedic828 (Sep 22, 2012)

abckidsmom said:


> In our area, those are high-risk calls.  Old people who "don't want to bother" us call for help getting up after their syncopal episode, hip fx, etc.  At least half of them are actually sick, and need to go to the hospital.



I think chase meant for a lift assist, not actual care.

FDNY dispatchs an engine for lift assists to ambulance crews who request it. They are usually onscene within 3-4 minutes.


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## abckidsmom (Sep 22, 2012)

NYMedic828 said:


> I think chase meant for a lift assist, not actual care.
> 
> FDNY dispatchs an engine for lift assists to ambulance crews who request it. They are usually onscene within 3-4 minutes.



Our area dispatches an engine for "I've fallen and can't get up."  I don't like it.


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## RocketMedic (Sep 22, 2012)

The ALS fly car is a legitimate option in many areas.


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## JPINFV (Sep 22, 2012)

Bullets said:


> Whats the ALS fix for Stroke?




What's the BLS fix that can't be provided by a taxi driver?

...oh, and rule out hypoglycemia.


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## Handsome Robb (Sep 23, 2012)

emtevan said:


> ive had many discussions about this and i dont care what people say emt-b's are very helpful and DO save lives.ive saved many and helped many people.Most calls are BLS anyways and it only becomes ALS because they put ekg's on people and give iv's.it's all how u use it and how good u are.Basics are just as good.



So helpful we don't even use them in the 911 system here. All AEMT/EMT-I and medics, every truck is ALS.

Example, I ran a syncope today with a BLS special events crew. Drunk guy fell down went boom and it came out as a syncope. Needless to say the BLS crew was a bit on the freaked side moving way to fast but making no meaningful progress. But hey, they looked damn good doing it!!


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## medicman14 (Sep 23, 2012)

NVRob said:


> So helpful we don't even use them in the 911 system here. All AEMT/EMT-I and medics, every truck is ALS.
> 
> Example, I ran a syncope today with a BLS special events crew. Drunk guy fell down went boom and it came out as a syncope. Needless to say the BLS crew was a bit on the freaked side moving way to fast but making no meaningful progress. But hey, they looked damn good doing it!!



Out of curiosity, using your logic... Since our entire State doesn't use aemt or emt-I, what does that say about them?


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## Brandon O (Sep 23, 2012)

JPINFV said:


> What's the BLS fix that can't be provided by a taxi driver?
> 
> ...oh, and rule out hypoglycemia.



Good information gathering and delivery to the best destination with appropriate resources mobilized. Y'know... same as every call.

Although I think I've started to believe that tPA is hardly worth doing, so it may be a bit academic. Stroke calls are like practice run: all the elements of an acute patient with none of the actual potential to help them!


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## NYMedic828 (Sep 23, 2012)

Brandon Oto said:


> Good information gathering and delivery to the best destination with appropriate resources mobilized. Y'know... same as every call.
> 
> Although I think I've started to believe that tPA is hardly worth doing, so it may be a bit academic. Stroke calls are like practice run: all the elements of an acute patient with none of the actual potential to help them!



Hospital is going to re-acquire every bit of information you provided. It doesn't serve as much purpose as you think.

I'm glad you've decided thrombolytic therapy isn't worth doing. Maybe the doctors will take your opinion into account the next time you bring in stroke. Research and studies found on the Internet are great for self education but until you devote 11 years of your life to studying medicine it isn't your decision to decide which route of definitive treatment is and is not appropriate. Your job is to take them to a stroke center, just incase. (Every hospital here is a stroke center)

I'm willing to bet that if you work in a busy area you have brought more than one patient in as a CVA and they were really hypoglycemic. So while it isn't actually a stroke, you presumed it to be. If you did rule in favor of hypoglycemia you still don't have the tools to fix it. Atleast not beyond what anyone else has in their kitchen.

As a paramedic, I am undereducated as can be. But, it's a good start. EMT is less than 200 hours in a lot of places and 100 of that is learning how to use carrying devices and scene safety. It's hardly more than basic first aid.

This isn't an attack but people are just being realistic here. Anyone with half a brain can figure out that if something is bleeding, you should cover it. CPR training has become very  common among society. Almost every BLS protocol has the words "call for ALS" in it. It is what it is.


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## Veneficus (Sep 23, 2012)

Brandon Oto said:


> Although I think I've started to believe that tPA is hardly worth doing, so it may be a bit academic



Just my opinion, but I don't think the problem is the tPA, I think it is how it is used that is the problem.

Just as PCI for revascularization of the heart, I think tPA as an adjunct to direct revascularization of the brain is where the benefit is realized.

As I have discussed many times, the seperation of surgery and medicine is entirely artificial. 

The use of IV systemic tPA is simply an attempt of medical treatment of a surgical disease. Why would anyone be shocked when it doesn't work nor produce studies demonstrating benefit?

Anytime you try to treat a surgical disease with medication all you do is delay the needed treatment.

Clotting agents, IV tPA, you name it, the dream of nonsurgeons using medicine to treat surgical diseases is alive and well. It is folly. But people fund research for it and pay lots of money to try.

Edit: think of it this way:

When your sink clogs, you pour the drano right into the pipe that is clogged right?

You do not pour the drano into the water connection to your house and hope it unclogs your sink.


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## Brandon O (Sep 23, 2012)

NYMedic828 said:


> Hospital is going to re-acquire every bit of information you provided. It doesn't serve as much purpose as you think.



Well, yes. Same as how we don't skip our assessment just because we took a report from a sending facility. But the relevant information can be found and assembled into a single, coherent block, so that the only thing which needs to occur is a quick confirmation. And appropriate resources can be prepared so that they're ready to go once that confirmation occurs. This is the same reason why our crashing trauma patients get more timely care when EMS brings them in than when they're dumped at the door by a taxi.

I podcasted about this recently with Dr. Walsh (I think I'm not allowed to post links here? it's in my profile if anyone's interested). He made a suggestion that I found insightful, which is that EMS making an effort to ensure that Joe or Jane family member who can verify time-of-onset -- and provide consent, when relevant -- is actually transported with the patient (not languishing in a personal vehicle or wherever) can be quite helpful. This is the sort of thing I mean. Yes, it'll eventually happen on its own, but not as quickly, and time is a factor.



> I'm glad you've decided thrombolytic therapy isn't worth doing. Maybe the doctors will take your opinion into account the next time you bring in stroke. Research and studies found on the Internet are great for self education but until you devote 11 years of your life to studying medicine it isn't your decision to decide which route of definitive treatment is and is not appropriate.



Er... I agree. Hence we're managing these patients as if they'll receive timely thrombolysis. I think we're all in agreement on that.



> I'm willing to bet that if you work in a busy area you have brought more than one patient in as a CVA and they were really hypoglycemic. So while it isn't actually a stroke, you presumed it to be and if you did rule out stroke in favor of hypoglycemia you still don't have the tools to fix it. Atleast not beyond what anyone else has in their kitchen.



We perform BLS glucometry, so no, but even barring that, I'm not certain that I understand what you're saying here.


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## Brandon O (Sep 23, 2012)

Veneficus said:


> When your sink clogs, you pour the drano right into the pipe that is clogged right?
> 
> You do not pour the drano into the water connection to your house and hope it unclogs your sink.



I agree that more targeted lytic therapy may prove to push the risk/benefit balance in the right direction -- in the future. I even think that systemic tPA as it's used now is probably overall beneficial in certain selected patient groups, which unfortunately I don't think we've adequately elucidated. But I also think that at this point in the research, "the dream is dead" and there's such a thing as accepting the evidence instead of wondering if maybe the dice will roll different with yet another trial... and also that eventually (and we're probably there) if you do find a benefit, it's clear that it won't be very large.

We get attached to therapies, especially when there aren't many other options. But they're not puppies.


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## Veneficus (Sep 23, 2012)

Brandon Oto said:


> I agree that more targeted lytic therapy may prove to push the risk/benefit balance in the right direction -- in the future. .



There are hospitals all over the world doing it now. 

The problem is it requires resources that not every hospital can commit to.

I am also familiar with multiple locations in the world that have multiple stroke centers in the same city, but only 1 of those centers in the given city actually perform direct arterial tPA by vascular surgeons or interventional radiologists. 

I am really not sure why neurosurgeons on not also training in the procedures on a larger scale. 

After all, cadiology found it very beneficial to both their income and prestige to adopt an interventional role.


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## JPINFV (Sep 23, 2012)

NYMedic828 said:


> Hospital is going to re-acquire every bit of information you provided. It doesn't serve as much purpose as you think.



If EMS did and documented a decent neuro exam (strength besides just feet pushes and hand squeezes, cranial nerves, sensation, DTRs, cerebellar tests. Most of this can be done in an ambulance, except maybe DTRs due to movement artifact), it would be very helpful in determining whether the stroke/TIA is recovering, progressing, or stable. The problem is that it has to be done and documented. EMS charts are actually reviewed in the ED, as well as by the inpatient team.


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## JPINFV (Sep 23, 2012)

Brandon Oto said:


> Good information gathering and delivery to the best destination with appropriate resources mobilized. Y'know... same as every call.



Most areas that I've seen require that BLS transport to the closest available receiving center, regardless of any specialty considerations. Also, good information gathering? So... how's your neuro exam?


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## NomadicMedic (Sep 23, 2012)

JPINFV said:


> Most areas that I've seen require that BLS transport to the closest available receiving center, regardless of any specialty considerations. Also, good information gathering? So... how's your neuro exam?



In looking at protocols for many different services, I see that the changes to mandate transport to a specialty center are being made. It seems as though medical directors are finally realizing that even BLS people can take stroke patients to stroke centers and chest pain patients to centers that have PCI capability


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## Brandon O (Sep 23, 2012)

JPINFV said:


> Most areas that I've seen require that BLS transport to the closest available receiving center, regardless of any specialty considerations.



Mass permits it, although just about everywhere is a stroke center anyway.



> information gathering? So... how's your neuro exam?



Pretty good. Need to work on my DTRs and Babinski, as well as operationalizing my cerebellar function tests. How's your hemorrhoids?


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## NYMedic828 (Sep 23, 2012)

Brandon Oto said:


> Mass permits it, although just about everywhere is a stroke center anyway.
> 
> 
> 
> Pretty good. Need to work on my DTRs and Babinski, as well as operationalizing my cerebellar function tests. How's your hemorrhoids?



Careful, he may be your boss one day. 

If I was working with someone and they began performing DTR evaluations/babinksi I would probably look at them like they had a few extra heads. Mainly because I would be in awe that I had a partner who knew what either one was...

Also, lost me at hemorroids?


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## medicsb (Sep 23, 2012)

Veneficus said:


> The use of IV systemic tPA is simply an attempt of medical treatment of a surgical disease. Why would anyone be shocked when it doesn't work nor produce studies demonstrating benefit?



For this to be true, it would have to be a known and established surgical disease.  Prior to tPA, the treatment for MI was largely placing the patient in a room, providing supportive treatment (e.g. morphine), and essentially praying that they don't die.  Was the treatment of CVA any different prior to tPA?  From what I can tell (skimming a few reviews of CVA management from the 70s) is that there was nothing to be done from a surgical standpoint and they were managed similarly to an MI (time and prayer).   If a pharmacologic therapy were to be successful, would it still be a surgical disease?  To declare it surgical and suggest that physicians have been ignoring the surgical nature is a bit Whiggish.  



> Clotting agents, IV tPA, you name it, the dream of nonsurgeons using medicine to treat surgical diseases is alive and well. It is folly. But people fund research for it and pay lots of money to try.



As if surgeons are jumping in to save the day from these crazy non-surgeons?  Again, ischemic stroke was medical and not surgical.  Just because surgeons found a way to manage the disease surgically, doesn't mean the previous physicians were fools for trying to manage them medically before surgery was ever an option.


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## medicsb (Sep 23, 2012)

n7lxi said:


> In looking at protocols for many different services, I see that the changes to mandate transport to a specialty center are being made. It seems as though medical directors are finally realizing that even BLS people can take stroke patients to stroke centers and chest pain patients to centers that have PCI capability



One day they might realize that CVA sans airway or hemodynamic problems is a "BLS" emergency and eliminate obligate ALS dispatches.  There's no reason a non-medic can't call a stroke alert.


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## Brandon O (Sep 23, 2012)

NYMedic828 said:


> If I was working with someone and they began performing DTR evaluations/babinksi I would probably look at them like they had a few extra heads.



To me, this type of deeper assessment is mainly useful when a patient is considering a refusal, or otherwise appears intact but you'd like to look a bit deeper. But if JP says there are receiving staff who'll use it to trend symptom development, I'll buy that too.



> Also, lost me at hemorroids?



You're such a charmer.


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## JPINFV (Sep 23, 2012)

NYMedic828 said:


> Also, lost me at hemorroids?



I'm assuming digital rectal exam.


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## JPINFV (Sep 23, 2012)

Brandon Oto said:


> To me, this type of deeper assessment is mainly useful when a patient is considering a refusal, or otherwise appears intact but you'd like to look a bit deeper. But if JP says there are receiving staff who'll use it to trend symptom development, I'll buy that too.



The question that's going to be answered is whether symptoms are improving or not. It's not that the ED and inpatient teams aren't going to be doing their own neuro exam, but if the inpatient team can go back another 30 minutes and get a trend that the patient is improving, then that can easily change the treatment decisions made.


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## Jambi (Sep 23, 2012)

JPINFV said:


> The question that's going to be answered is whether symptoms are improving or not. It's not that the ED and inpatient teams aren't going to be doing their own neuro exam, but if the inpatient team can go back another 30 minutes and get a trend that the patient is improving, then that can easily change the treatment decisions made.



How detailed does it need to be so that it useful?  I've been using the "MEND" exam on my patients.  No one knows what it is out here so I just document things individually.

http://www.asls.net/mend.html


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## Veneficus (Sep 23, 2012)

medicsb said:


> For this to be true, it would have to be a known and established surgical disease.



Sepsis is a surgical disease... At least according to Fischer's Master of Surgery.



medicsb said:


> Prior to tPA, the treatment for MI was largely placing the patient in a room, providing supportive treatment (e.g. morphine), and essentially praying that they don't die.  Was the treatment of CVA any different prior to tPA?  From what I can tell (skimming a few reviews of CVA management from the 70s) is that there was nothing to be done from a surgical standpoint and they were managed similarly to an MI (time and prayer)..



That was part of my post...

However, with the recognition of the discipline of vascular surgery and its counterparts in interventional radiology and cardiology respectively, it seems to me obvious that the future the prefered treatment of vascular occlusion in any part of the body is going to be surgery for at least my lifetime. 

In my mind, that makes it a surgical disease. (a disease primarily treated by surgeons) Whether the more medical minded people wish to concede that or not is really irrelevant. 

Whether or not traditionally medical disciplines are performing vascular "procedures" it is still surgery. I renew my position that the lines drawn between medicine and surgery are for the convenience of practicioners, not as the best way to practice medicine.

Whether you are talking about vascular intervention, an ED, OB/Gyn, orthopedics, or even anesthesia, everyone has their surgical proedures. I highly suspect that as we refine which treatments work most of the time, there will be more of a merging between disciplines. I would say it is simply revolution. As not 100 years ago, there were not nearly the number of specialty disciplines there are today.



medicsb said:


> If a pharmacologic therapy were to be successful, would it still be a surgical disease?



I would say "no." But as i have explained and we have seen with PCI, at this point in time, medical treatment is not working.



medicsb said:


> To declare it surgical and suggest that physicians have been ignoring the surgical nature is a bit Whiggish



I was not trying to say that past physicians ignored the surgical nature of it. Obviously they did the best they had with the technology of the time. But I think it is important that we realize and admit the obviousness of the truth. In this age, it is vascular intervention which will most likely carry the day.

If you recall, in our career, community hospitals once without PCI used to find reasons and make guidlines for pharmacological treatment instead of immediately shipping the patient to a PCI lab. Still to this day we haven't globally mandated EMS take STEMI patients directly to a PCI center. (We do talk about it like it is best practice though) 

I see this as more of the same only at the medicine level.  



medicsb said:


> As if surgeons are jumping in to save the day from these crazy non-surgeons?  Again, ischemic stroke was medical and not surgical.  Just because surgeons found a way to manage the disease surgically, doesn't mean the previous physicians were fools for trying to manage them medically before surgery was ever an option.



I am not suggesting they were. But medicine or surgery are not the quickest to embrace change. Whether there is evidence or not.


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## NYMedic828 (Sep 23, 2012)

Veneficus said:


> However, with the recognition of the discipline of vascular surgery and its counterparts in interventional radiology and cardiology respectively, it seems to me obvious that the future the prefered treatment of vascular occlusion in any part of the body is going to be surgery for at least my lifetime. .



Random question.

I know an ultrasound device can sometimes be used to break up a kidney stone. Why can't that same method be used in a cerebral pathology? (I imagine the distance the waves must travel and the structures they pass through come into play)


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## RocketMedic (Sep 24, 2012)

As a guess, I'd reckon it's both the skull and that kidney stones are hard and resonate, while thrombuses are "soft" and don't break up as easily.


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## JPINFV (Sep 24, 2012)

Rocketmedic40 said:


> As a guess, I'd reckon it's both the skull and that kidney stones are hard and resonate, while thrombuses are "soft" and don't break up as easily.



Plus 1 clot vs multiple down stream clots since the clot is broken up instead of broken down.


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## Handsome Robb (Sep 24, 2012)

medicman14 said:


> Out of curiosity, using your logic... Since our entire State doesn't use aemt or emt-I, what does that say about them?



That medics in your state have to do a lot more since their EMT-B partner can't do a whole lot to help, procedure-wise, on acute patients, or even non-acute ALS patients. 

That's what it means.

I'll take an EMT-I or AEMT over a basic as a partner any day of the week. 

I'm not trying to be disrespectful but if you have 1 medic and 4 basics on a cardiac arrest that means the medic is not only having to gather information from the family but also control the airway, gain IV/IO access, draw and push meds and run the monitor all while directing the orchestra. 

Whereas on arrests I stand back while my partner and our ILS FDs do all of the above while I manage the scene and don't get trapped doing skills. Sure antidysrhythmics are all me but other than that my partner and coresponders can do the rest while I focus on keeping everything moving in the right direction.

See my point?


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## NYMedic828 (Sep 24, 2012)

NVRob said:


> That medics in your state have to do a lot more since their EMT-B partner can't do a whole lot to help, procedure-wise, on acute patients, or even non-acute ALS patients.
> 
> That's what it means.
> 
> ...



Half agree, but not because your points are invalid.

Personally I would MUCH rather work with an EMT than a medic partner because 9/10 medics I work with are incompetent and miserable people. They don't want to be criticized or judged because they have it in their head that they are awesome and can do no wrong. It's a NYC attitude to begin with that is just exacerbated by the job.

It often hinders care because they find treatments like antiemetics and pain management to be a "waste of their time."

An EMT partner is more likely to listen to a person "above" them and use the criticism to improve because they assume that higher person to be correct (usually). An EMT working consistently with a medic also allows that EMT to progressively grow and learn. I would have no problem allowing an EMT partner to draw up meds, hang IVs and whatnot once I am comfortable with them.

If I could work with people on this forum id be a much happier individual.


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## VFlutter (Sep 24, 2012)

NYMedic828 said:


> If I could work with people on this forum id be a much happier individual.



I have accepted the fact that I am pretty much worthless as an EMT-B after being off the trucks for a year. I would be putting the KED on upside down and shoving LMAs in the wrong orifice :blink:


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## Veneficus (Sep 24, 2012)

JPINFV said:


> Plus 1 clot vs multiple down stream clots since the clot is broken up instead of broken down.



This without caveat or condition.


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## TransportJockey (Sep 24, 2012)

NVRob said:


> That medics in your state have to do a lot more since their EMT-B partner can't do a whole lot to help, procedure-wise, on acute patients, or even non-acute ALS patients.
> 
> That's what it means.
> 
> ...



Granted I hate working wiht basics cause my workload gets doubles usually, but at least here a medic working a code wiht 2 basics and a couple first responders (if we're lucky, I've worked a two person (m/b) code before, that sucks), the basics can control airway with a combi or king, while I get access and run the code.


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## DrParasite (Sep 24, 2012)

TransportJockey said:


> Granted I hate working wiht basics cause my workload gets doubles usually, but at least here a medic working a code wiht 2 basics and a couple first responders (if we're lucky, I've worked a two person (m/b) code before, that sucks), the basics can control airway with a combi or king, while I get access and run the code.


I hated working on a B/P crew.  also hated working on a B/P/RN crew.  I much rather preferred B/B and P/P (tiered system).

The reason was quite simple: on a B/P crew, the paramedic treats the sick patients, while the basic drives.  All too often this results in the basic being absolutely clueless on what to do on a sick patient, because they always need the medic to hold their hand on what they do.  If the patient is stable, the EMT does the stare of life, but they really don't get much experience with the sick people.  Now if you are a good medic and you do teach your emt how to do things, why things are done, and you don't relegate them to carrying equipment and driving, than more power to you, but I think you are the rarity rather than the norm.

That's why when people on these forums talk about EMTs not knowing what to do when faced with a sick patient, or panicing and running around like a chicken with their head cut off, I have to ask how much experience do they really have dealing with sick people when they don't have a medic there to hold their hand.

btw, the only way I think a B/P system works is if you have a flycar P available for those big calls, calls that you need a second paramedic.  cardiac arrests, major traumas, CPAP and RSI cases, sometimes you just need the second pair of skilled hands to assist in treating the patient properly. otherwise it's very easy to miss something, esp if you are trying to everything solo.


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## gfb21t (Sep 24, 2012)

hey, can you fail the pa emt written test if you don't show up


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## NYMedic828 (Sep 24, 2012)

gfb21t said:


> hey, can you fail the pa emt written test if you don't show up



You certainly can't pass it...


Totally unrelated to the thread...


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## rescue1 (Sep 24, 2012)

I currently work in a B/P system and I can see the issues with the vast differences in scope between myself and the paramedic. My main issue is that there are many patients that deserve an ALS assessment before they could truly be downgraded to BLS, and once an ALS assessment is performed, there is really no reason for the medic not to take the call (since now they have to do a chart, assuming a 4 lead or a glucometer was done). You therefore have two issues, the first being that all I do is drive and carry stuff on important calls.

The second issue is that since we are dispatched either BLS (cold response) or ALS (hot response), the crew arrives on scene with preconceived notions of whether it will be a basic or advanced call. Therefore, there is some pressure not to be "that basic" who gets everything upgraded to ALS or "that medic" who turfs everything down. 
Therefore you get situations where two patients with almost identical symptoms will get different levels of care, because one came in as ALS and one BLS. This is mostly an issue with lazy medics.
Now, its not an insurmountable obstacle, and I'm lucky enough to have a good working relationship with my medic partner, but the issue is there. If you ask me it's an issue that needs fixing, because there's no reason for the patient not to have the best care for their condition, whether it be BLS or ALS. Many medics have stories about pts who they checked just to take the work off their EMT partner who had been providing all day, only to find that this "BLS" pt was having an MI or something similar. We shouldn't be finding MIs based off only dispatch information and random chance.

If I had my AEMT (PA doesn't have ILS...AEMT is supposed to be coming), then any "rule out" assessments such as a 4-lead could be performed by me, allowing a transport decision to be made without making everything ALS, which would certainly lessen the above issue.

I'm also a fan of a dual response system with medic chase cars, but again, this requires good assessment skills from BLS providers, which I can certainly tell you I wasn't taught in class.


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## Brandon O (Sep 24, 2012)

rescue1 said:


> If I had my AEMT (PA doesn't have ILS...AEMT is supposed to be coming), then any "rule out" assessments such as a 4-lead could be performed by me, allowing a transport decision to be made without making everything ALS, which would certainly lessen the above issue.



Not sure what a "4-lead" (meaning a four-electrode ECG) would help you rule out, or for that matter, what it would help you rule in that you could treat at that level?


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## rescue1 (Sep 24, 2012)

12-lead, my bad.

As for treatment, my point would be that if the second provider had the ability to interpret ECG readings, that would remove the institutional pressure not to make calls ALS for assessment only. If the basic provider could look at the 12 lead and say "nope, no problems", he can also write the chart, handle care, etc. If he looks and sees trouble, then the medic can upgrade.

The way it works now is that since every ECG is an ALS call by definition, there are patients that do not receive a full assessment because of the idea of "if it's dispatched BLS, it's BLS", and there are basics and medics who subscribe to this (wrong) idea. Like I said above, if my unit is sent to an "ALS sick person", they will get an ALS assessment. If it's a "BLS sick person", its likely they will get a BLS assessment. This is the same even if the patient has identical symptoms (assuming those symptoms aren't automatically ALS in nature). Therefore you get patients who slip through the cracks since they present with non obvious symptoms.


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## Brandon O (Sep 24, 2012)

rescue1 said:


> 12-lead, my bad.



Yes, that would be nice, although if you're going to be interpreting it on your own (not sure your scope over there) that's quite another can of worms.

Probably more than two-thirds of the time I look for ALS it's merely to get a 12-lead done and rule out ACS, but most of the medics in my current system aren't comfortable kicking down the call once they've put electrodes on a chest, so they end up taking 'em anyway even when it's negative.


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## rescue1 (Sep 24, 2012)

What you just explained was basically my point above...ECG done, its ALS, no reason to turf it.


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## Brandon O (Sep 24, 2012)

rescue1 said:


> What you just explained was basically my point above...ECG done, its ALS, no reason to turf it.



Well, the reason would be to free up the ALS unit, just like always. The fact that they've already spent some time here doesn't change that.

The main reason medics like to stay on these calls is liability; they don't want to be the guy who sent away the big one, especially when they're not completely confident in their ability to rule it out using the ECG. (And of course, with some equivocal patients they shouldn't be doing so -- but there are plenty of generally well folks with a minor complaint who just need a quick screen to make sure they're not trying to sneak by a gigantor STEMI with an atypical presentation.

Horses for courses, I suppose.


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## rescue1 (Sep 24, 2012)

I feel with fly cars the issue is lessened. If you make the response in a chase car, you have paperwork to do, period. Therefore, assessments are no skin off your back.

In a truck with a medic and a basic, there can be pressure for a call that appears to be BLS to stay that way, because a lazy medic won't want to do a full assessment since that means he suddenly has a chart to do.

Is that practice acceptable? No. But it happens.


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## TransportJockey (Sep 24, 2012)

I am not a fan of chase cars due to the simple fact that with a 3.5k sq mi service area, most of it very rural, they are not practical. And that's where it becomes more economical to make each truck at least ILS level, if not ALS level.


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## RocketMedic (Sep 25, 2012)

Definitely this, but its not insurmountable. AMR Otero's supervisors run an ALS fly car.


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## TransportJockey (Sep 25, 2012)

Rocketmedic40 said:


> Definitely this, but its not insurmountable. AMR Otero's supervisors run an ALS fly car.



That they do, but Otero, in the scheme of things in NM, has a relatively high population density. It's not the extreme ruralness of areas like Pecos TX (which oh dear god it sucked)


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## Bullets (Sep 25, 2012)

Unfortunately the science out there is changing the way we view our advanced practitioners.  All these ACLS drugs may not actually do anything and might just harm patients.  Medics can't tube reliably,  stroke patients really need someone to pick them up and go to the hospital.  

Unless there is a change in the attitude of in medics around here,  Emts will remain.  If I called ALS for pain management I would get laughed at and they would leave.  Very rarely do they release to basics even if all they do is the stare of life.  And when I do ask for them to do an assessment on patient who isn't visibly circling the drain I usually get an attitude.  And this its true for multiple ALS agencies


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## DrParasite (Sep 25, 2012)

Bullets said:


> Unless there is a change in the attitude of in medics around here,  Emts will remain.  If I called ALS for pain management I would get laughed at and they would leave.  Very rarely do they release to basics even if all they do is the stare of life.  And when I do ask for them to do an assessment on patient who isn't visibly circling the drain I usually get an attitude.  And this its true for multiple ALS agencies


Sounds like you have worked with the JC medics.


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## Tigger (Sep 25, 2012)

Bullets said:


> Unfortunately the science out there is changing the way we view our advanced practitioners.  All these ACLS drugs may not actually do anything and might just harm patients.  Medics can't tube reliably,  stroke patients really need someone to pick them up and go to the hospital.
> 
> Unless there is a change in the attitude of in medics around here,  Emts will remain.  If I called ALS for pain management I would get laughed at and they would leave.  Very rarely do they release to basics even if all they do is the stare of life.  And when I do ask for them to do an assessment on patient who isn't visibly circling the drain I usually get an attitude.  And this its true for multiple ALS agencies



If ALS was dispatched on the initial dispatch do you think the same patient would get pain medication? If not, why not?


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## Bullets (Sep 26, 2012)

Tigger said:


> If ALS was dispatched on the initial dispatch do you think the same patient would get pain medication? If not, why not?



No, i doubt they would get pain medication

A.) unless its a serious trauma/MVC  Medics arent routinely dispatched  for most  non-medical calls if there isnt a report of LOC. 

B.) if they are sent they usually are focused on other things besides pain management. BLS is doing the wound care and bandaging, while ALS usually secures two lines and the airway when needed

I can think of only a few times a patient has received pain meds and this is having experience with  many different ALS agencies


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## RocketMedic (Sep 26, 2012)

Bullets said:


> No, i doubt they would get pain medication
> 
> A.) unless its a serious trauma/MVC  Medics arent routinely dispatched  for most  non-medical calls if there isnt a report of LOC.
> 
> ...



It sounds like the paramedics you work with totally suck, dude. Pain management is an important part of patient care, and although there are circumstances where we cannot manage pain (ie pregnant female with abdominal pain) per protocol, there are plenty of patients where we can. It's both the medically and ethically right thing to do.


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## Veneficus (Sep 26, 2012)

Rocketmedic40 said:


> It sounds like the paramedics you work with totally suck, dude. Pain management is an important part of patient care, and although *there are circumstances where we cannot manage pain (ie pregnant female with abdominal pain) per protocol*, there are plenty of patients where we can. It's both the medically and ethically right thing to do.



That is the key phrase.

With simply another tool in the box you could.


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## RocketMedic (Sep 26, 2012)

Veneficus said:


> That is the key phrase.
> 
> With simply another tool in the box you could.




No disagreement, but that predicates additional training, resources and medical direction that most American paramedics don't have in-hand. That Bullet's paramedics are apparently not even managing isolated, non-complicated pain implies either apathy/incompetence, restrictive medical direction, or reporter bias.

Jersey, in other words.


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## Veneficus (Sep 26, 2012)

Rocketmedic40 said:


> No disagreement, but that predicates additional training, resources and medical direction that most American paramedics don't have in-hand. That Bullet's paramedics are apparently not even managing isolated, non-complicated pain implies either apathy/incompetence, restrictive medical direction, or reporter bias.
> 
> Jersey, in other words.



just switch out morphine for meperidine.

problem solved.


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## Doczilla (Sep 26, 2012)

Ewwwwww.


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## NomadicMedic (Sep 26, 2012)

We are routinely requested by BLS for pain management. If they call, we'll go. However, I find it frustrating when they call us for pain management after they've moved granny from the floor, down two flights of stairs to the Ambulance and have gone en route to the hospital. 

But, I'd rather they keep calling and act as patient advocates (as much as they can). I just educate them about early pain management and start the line.


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## RocketMedic (Sep 26, 2012)

Doczilla said:


> Ewwwwww.



???


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## Bullets (Oct 6, 2012)

So after further investigation, ALS only carries morphine for chest pain protocol and has no standing orders for pain management. They would have to call medical control and get special permission.  Basically I was told that pain isn't a life threat and thus not an ALS job. 

Nice


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## JPINFV (Oct 6, 2012)

Bullets said:


> So after further investigation, ALS only carries morphine for chest pain protocol and has no standing orders for pain management. They would have to call medical control and get special permission.  Basically I was told that pain isn't a life threat and thus not an ALS job.
> 
> Nice



I hope whoever said that gets to sit in the emergency department with 10/10 pain because "pain is a med/surg issue, not an ED issue."


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## RocketMedic (Oct 6, 2012)

JPINFV said:


> I hope whoever said that gets to sit in the emergency department with 10/10 pain because "pain is a med/surg issue, not an ED issue."



Jersey. Poor, misserved Jersey.


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## VFlutter (Oct 6, 2012)

Pain is just weakness leaving the body....so if we treat the pain aren't we keeping the weakness in? Or something like that


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## EpiEMS (Oct 6, 2012)

Bullets said:


> So after further investigation, ALS only carries morphine for chest pain protocol and has no standing orders for pain management. They would have to call medical control and get special permission.  Basically I was told that pain isn't a life threat and thus not an ALS job.
> 
> Nice



That's insane. What a silly way to design a system.


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## jemt (Oct 7, 2012)

Bullets said:


> So after further investigation, ALS only carries morphine for chest pain protocol and has no standing orders for pain management. They would have to call medical control and get special permission.  Basically I was told that pain isn't a life threat and thus not an ALS job.
> 
> Nice



Incorrect, pain management can be used on a variety of things, it just needs approval by med control. I've witnessed Morphine given in the field for abdominal pain by ALS.


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## Bullets (Oct 7, 2012)

jemt said:


> Incorrect, pain management can be used on a variety of things, it just needs approval by med control. I've witnessed Morphine given in the field for abdominal pain by ALS.



In NJ? The copy i have of the MICU protocols only allows for pain management in severe burn/traumas.

Obviously with medical control anything can be changed


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## hogwiley (Oct 7, 2012)

I think the basic level should be Advanced EMT or EMT specialist, but since nobody has ran a specialist class anywhere in my state for at least 3years, Ive been stuck a basic for now. 

At least until somebody volnteers to pay my bills along with my tuition for a year and a half while I go to Paramedic school, especially since Id have to relocate as there are no schools around me. 

Anyway, why stop at eliminating EMT Basic, why not require an associates degree for Paramedic, and require the same science and math classes RN school does? How many Paramedics have passed college level anatomy and physiology? You probably have more EMT Basics that have since many Basics are also allied health care professionals who volunteer in EMS.


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## DrParasite (Oct 8, 2012)

Bullets said:


> In NJ? The copy i have of the MICU protocols only allows for pain management in severe burn/traumas.


I find it very hard to believe that those doctors and allied healthcare providers would fail to add a pain management for medical pain or non-severe trauma...

oh wait, I have been in NJ for 15 years, that's pretty much what I have seen. You would think 10+ years of schooling and M.D. after your name would result in better protocols.


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## hogwiley (Oct 8, 2012)

Im with a rural non transporting volunteer BLS first responder unit. Do you honestly think we could staff our agency with all Paramedics? So do away with EMT Basics and who replaces them in places like this? 

Obviously no one would, so instead of having an EMT there in minutes, youll have an ALS rig with Paramedics first on scene 45 minutes later. Dont worry, im sure the Paramedics can make up that extra 40 minutes because they have an extra year of vocational ed(with no pre requisites).

Basing on what Ive personally observed over the past few years, in very few cases did ALS save a patient that would have died had it been BLS, and I cant think of seeing any calls where having two medics on scene instead of a medic and an EMT saved someones life. Im sure somewhere at some point it may have occured, but I havent seen it. Im sure having MDs on every rig would occasionally make a difference as well, but thats cost prohibitive, so you have to weigh the value with the cost. 

Usually if the patient is in bad shape, its load em and go. As for pain management, does it really matter if you have two medics instead of one medic and a basic showing up in a rig? 

Despite all the squawking about EMTs on here, the reason EMT Basic exists is probably because the people with MD by their name understand what saves patients is getting them to definitive care quickly, not whether the person driving the ambulance has an extra year of vocational ed.


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## NYMedic828 (Oct 8, 2012)

hogwiley said:


> Im with a rural non transporting volunteer BLS first responder unit. Do you honestly think we could staff our agency with all Paramedics? So do away with EMT Basics and who replaces them in places like this?
> 
> Obviously no one would, so instead of having an EMT there in minutes, youll have an ALS rig with Paramedics first on scene 45 minutes later. Dont worry, im sure the Paramedics can make up that extra 40 minutes because they have an extra year of vocational ed(with no pre requisites).



1. Nurses. More abdundant and more educated than 9/10 paramedics.

2. A year of college level vocational training substantially different than three weeks of middle school level training.

Paramedic is at a subpar educational standard but an EMT class can be replaced with a week of employer provided training.


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## Veneficus (Oct 8, 2012)

hogwiley said:


> Im with a rural non transporting volunteer BLS first responder unit. Do you honestly think we could staff our agency with all Paramedics? So do away with EMT Basics and who replaces them in places like this?.



I think the issue is a bit more complex than this. In many countries, volunteer ambulance corps exist, and as a function of the state, medics are rotated through rural communities.

It doesn't take an EMT to drive somebody to the hospital. With the model of basic EMS first response, it means everyone goes to the hospital. Which is not a sustainable economic model. 

I think it is important to seperate the fuctions of patient care and transport in EMS. A more advanced provider can decide if the patient needs to go to the hospital at all or a better place to refer them.  



hogwiley said:


> Obviously no one would, so instead of having an EMT there in minutes, youll have an ALS rig with Paramedics first on scene 45 minutes later. Dont worry, im sure the Paramedics can make up that extra 40 minutes because they have an extra year of vocational ed(with no pre requisites).



How many minutes more than 6? What good is a provider with only a handful of interventions that don't address most modern medical problems outside of the hospital?

As for an extra year of training, if you measure it in actual hours, an ALS provider has between 7 and 10x (depending on old or new curriculum respectfully) So the question must be reversed. Not what can an ALS provider add, but what can a BLS provider actually do? 



hogwiley said:


> Basing on what Ive personally observed over the past few years, in very few cases did ALS save a patient that would have died had it been BLS, and I cant think of seeing any calls where having two medics on scene instead of a medic and an EMT saved someones life. Im sure somewhere at some point it may have occured, but I havent seen it. Im sure having MDs on every rig would occasionally make a difference as well, but thats cost prohibitive, so you have to weigh the value with the cost.



Since the value of EMS in saving lives is so minimal, I am not surprised by your experience. Additionally, it has been identified in multiple studies that patients who call EMS overwhelmingly do not need life saving intervention but do need medical care. That makes a basic EMS service a very overpriced taxi.

As for having 2 medics, I agree most calls will not require 2 medics. During my time working as a medic, there were many more interpersonal issues on double medic trucks. There is also the problem of skill dilution. However, again, countries outside the US have managed to make it work. It is more of a question of system design than individual qualification.

Having an MD on the ambulance is only cost prohibitive because of the system of reimbursement. There is no data, but I am willing to bet that it costs less to have a physician who can treat/release/prescribe riding around than to initiate an emergency ambulance and the cost of an ED for majority who do need healthcare but do not need an ED.  



hogwiley said:


> Usually if the patient is in bad shape, its load em and go. As for pain management, does it really matter if you have two medics instead of one medic and a basic showing up in a rig?



If the patient is that bad and that far away from a hospital that actually can help and not the local doc in a box community hospital, then it isn't going to matter anyway. But again, if 5% of all EMS calls are non emergent, why are we staffing an expensive taxi in a system that costs more than it helps?

As for pain management, it is not a question of 1, 2, or 10 medics on the ambulance, it is a question of having somebody who is able to do it. 2 medics on an ambulance can control pain as well as 1. But 2 basics on an ambulance cannot.



hogwiley said:


> Despite all the squawking about EMTs on here, the reason EMT Basic exists is probably because the people with MD by their name understand what saves patients is getting them to definitive care quickly, not whether the person driving the ambulance has an extra year of vocational ed.



That is an interesting tag line. 

I believe that many MDs are just not interested in dealing with any part of the EMS system. I also believe that the reimburement model makes it impossible for MDs to alter the system design without changing the way it is funded, not because they approve of the system. 

I think that effective stabilizing care can be borought to the patient. I think in many conditions, this immediate care may not save lives, but it is shown it reduces hospitalization length. 

If having ALS providers saves every patient who used the 911 system 1 or 2 days in an ICU or inpatient ward, the cost savings will quickly be realized by the system.

"Saving lives" is a very poor measure of an EMS system. It reflects a time when we didn't know as much about disease as we do today. It reflects a time when we thought many illnesses were sudden in onset and unpredictable. Today, the value of EMS is to manage acute exacerbations of chronic medical conditions. 

That sudden MI actually started as fatty streaks as a fetus. In a female, it was hormonally delayed. If a patient has their first "sudden" MI at 55, that means it was more than 55 years in the making with subclinical symptoms.

It is not like basics never had value, it is that as we learn more, the minimal service they provide becomes less and less valuable.


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## TransportJockey (Oct 8, 2012)

hogwiley said:


> Im with a rural non transporting volunteer BLS first responder unit. Do you honestly think we could staff our agency with all Paramedics? So do away with EMT Basics and who replaces them in places like this?
> 
> Obviously no one would, so instead of having an EMT there in minutes, youll have an ALS rig with Paramedics first on scene 45 minutes later. Dont worry, im sure the Paramedics can make up that extra 40 minutes because they have an extra year of vocational ed(with no pre requisites).



If it's like the county I run paid 911 in, they have to wait for the paid ILS or ALS unit to show up before they get any care anyways. The volly departments are lucky if they respond to 10% of the calls, and at this point we just automatically assume they don't exist until they mark en route. And even at that point we usually beat them to scene and cancel them. 
I'm sorry, but if you can put a private 911 service in one of the poorest counties in one of the poorest states in the country (which we are!), there's no excuse to not have guaranteed 24/7 coverage.


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## Veneficus (Oct 8, 2012)

*correction*

In my above post, that should read if 95% of calls are non-emergent. 

In my multitasking fail, I didn't notice I didn't press hard enough on the 9 key.


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## Tigger (Oct 8, 2012)

hogwiley said:


> Despite all the squawking about EMTs on here, the reason EMT Basic exists is probably because the people with MD by their name understand what saves patients is getting them to definitive care quickly, not whether the person driving the ambulance has an extra year of vocational ed.



A successful EMS system cannot be based around the premise of saving lives but rather delivering the proper degree of healthcare to the population that it serves. 

Just because the patient is not fixing to die in your ambulance doesn't mean that the patient is not sick. A sick patient needs treatment, a paramedic can offer that, a basic cannot. You cannot say that holding someone's hand is an acceptable alternative to Zofran, it's either you help the patient, or you do not.


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## Asclepius911 (Oct 8, 2012)

This blog brings me back when a nurse referred to us as "the taxi" or nurse that only cared for vitals and did not want to listen to the rest of the assessment/report. In Los Angeles County we are looked upon as ambulance drivers. It feels a bit degrading at times, similarly like a monkey that response to his name and at the same time can do some cool tricks. Lol 

Now let's begin sarcasm with metaphors/simile. Let's look at the medical circus? sassy RNs are the mustached women, security are the strongest men, Drs are acrobats you see them at a distance flying around?


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## hogwiley (Oct 8, 2012)

TransportJockey said:


> If it's like the county I run paid 911 in, they have to wait for the paid ILS or ALS unit to show up before they get any care anyways.



Well depends on what you mean by care, the faster you get them to a hospital, the faster they get definitive care. If you are substantially delaying their transport because you insist on having Paramedics take them, are you giving them better faster care?



> The volly departments are lucky if they respond to 10% of the calls, and at this point we just automatically assume they don't exist until they mark en route. And even at that point we usually beat them to scene and cancel them.



So why is this volly department only responding to 10% of the calls? Is this all they are dispatched to, or all they respond to when dispatched? Either way something doesnt make sense. As for beating them to the scene, I can say that I personally have never seen that happen where Im at. Usually its a substantial wait before ALS gets there. 

Imagine its winter and someone crashes their snowmobile into a tree on some remote logging trail. Would you want local EMTs who know the area well responding, or would you just prefer to wait out there in 5 degree weather while some non local Paramedics get lost repeatly while trying to get to you? Once they do get to you what are they gonna do prior to getting you into the ambulance? Pretty much the exact same thing we'd do. I know, Ive seen both sides of it doing ambulance clinicals with an ALS company and responding as an EMT and I didnt see anything done differently, except in the case where ALS handled it themselves the patients were suffering from hypothermia by the time they made it into the ambulance(almost the same thing on some car wrecks around here).


> I'm sorry, but if you can put a private 911 service in one of the poorest counties in one of the poorest states in the country (which we are!), there's no excuse to not have guaranteed 24/7 coverage.



The poorest areas often get federal or state aid. Around here the poorest township has some of the best and most modern EMS equipment because they get federal aid and grants. Its the ones that arent as poor that have to pretty much fend for themselves because they dont qualify, and the public is usually less than enthusiastic about paying higher taxes for better EMS. 

EMS is kind of a red headed step child when it comes to health care. People want the best hospitals staff and doctors, but EMS is generally an afterthought, especially in rural areas where people figure they are often better off just having someone drive them to the ER than waiting for an ambulance. I almost never see pediatric calls unless its something really bad because people just snatch the little ones up and drive rather than wait. Youd also be amazed at the condition of some of the patients that walk into the ED around here.


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## TransportJockey (Oct 8, 2012)

hogwiley said:


> Well depends on what you mean by care, the faster you get them to a hospital, the faster they get definitive care. If you are substantially delaying their transport because you insist on having Paramedics take them, are you giving them better faster care?


I mean any kind of care at all. All of my company's trucks run at least ILS level, most are ALS. We beat FD to a majority of the calls in the county, and a good amount in the three municipalities w/ combo depts.


> So why is this volly department only responding to 10% of the calls? Is this all they are dispatched to, or all they respond to when dispatched? Either way something doesnt make sense. As for beating them to the scene, I can say that I personally have never seen that happen where Im at. Usually its a substantial wait before ALS gets there.


We have 9 Rescue districts, each a separate fire department loosely under the county Fire Marshall. 2 are Combo Departments w/ someone on the trucks 24/7. We have 1 district (9) that is literally responding to 10% of the medical calls dispatched in their district. And a good portion of the other 6 volly only districts w/ a rescue respond to maybe 25% of their medical calls during the day and maybe 40% at night. No one wants to be a volly, not that I blame them. Hell, the only reason I volly in another rural county (not where I live, since ABQ doesn't use vollys) is because they pay for classes for me. If they didn't offer that I wouldn't bother.


> Imagine its winter and someone crashes their snowmobile into a tree on some remote logging trail. Would you want local EMTs who know the area well responding, or would you just prefer to wait out there in 5 degree weather while some non local Paramedics get lost repeatly while trying to get to you? Once they do get to you what are they gonna do prior to getting you into the ambulance? Pretty much the exact same thing we'd do. I know, Ive seen both sides of it doing ambulance clinicals with an ALS company and responding as an EMT and I didnt see anything done differently, except in the case where ALS handled it themselves the patients were suffering from hypothermia by the time they made it into the ambulance(almost the same thing on some car wrecks around here).


Not applicable here. Our units run this county from top to bottom, we know the county damn near the same as the vollies in their districts. If I am told a rough area of the county, I can find a way to get there PDQ. 


> The poorest areas often get federal or state aid. Around here the poorest township has some of the best and most modern EMS equipment because they get federal aid and grants. Its the ones that arent as poor that have to pretty much fend for themselves because they dont qualify, and the public is usually less than enthusiastic about paying higher taxes for better EMS.


Here in NM it seems the poorest areas still have issues getting equipment for EMS care. Fire apparatus is one thing, but Ambulances and supplies are still hard to come by. If by chance a volly unit beats me to scene and starts care and uses supplies, I am expected to restock them from my unit because their supply budget is nil.


> EMS is kind of a red headed step child when it comes to health care. People want the best hospitals staff and doctors, but EMS is generally an afterthought, especially in rural areas where people figure they are often better off just having someone drive them to the ER than waiting for an ambulance. I almost never see pediatric calls unless its something really bad because people just snatch the little ones up and drive rather than wait. Youd also be amazed at the condition of some of the patients that walk into the ED around here.



No argument there. I've worked in an ER as a tech and seen some pretty F'ed up patients walk in. But because my county doesn't have a hospital at all, we intercept a lot with vehicles on the side of the road because they wanted to head to the hospital then realized that the patient was in a really bad way and needed medical care.


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## Tigger (Oct 8, 2012)

hogwiley said:


> Well depends on what you mean by care, the faster you get them to a hospital, the faster they get definitive care. If you are substantially delaying their transport because you insist on having Paramedics take them, are you giving them better faster care?
> 
> 
> 
> ...



Significant trauma is not the by any stretch of the imagination the majority of what EMS responds to though. Sure, in this case transport to the hospital is what is needed. But we can do better than that for our medical patients. Is the dehydrated patient with some serious nausea and vomiting going to die during a BLS transport? Nah, probably not. But they would be a lot more comfortable going ALS, make no mistake.


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## Veneficus (Oct 8, 2012)

Tigger said:


> Significant trauma is not the by any stretch of the imagination the majority of what EMS responds to though. Sure, in this case transport to the hospital is what is needed. But we can do better than that for our medical patients. Is the dehydrated patient with some serious nausea and vomiting going to die during a BLS transport? Nah, probably not. But they would be a lot more comfortable going ALS, make no mistake.



I would argue that ALS can make a difference in trauma.

In addition to decompressing a tension pneumo, which can be life saving, and ALS provider may not be as apt to over triage to airmed and cost the patient and the system 10s of thousands of dollars.


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## usalsfyre (Oct 8, 2012)

hogwiley said:


> Well depends on what you mean by care, the faster you get them to a hospital, the faster they get definitive care. If you are substantially delaying their transport because you insist on having Paramedics take them, are you giving them better faster care?
> 
> 
> 
> ...



So essentially you are arguing that the only reason to keep the volley system in place is because you're already there? Not a particularly strong argument. Most rural systems internationally have a volley first response component, this is not what anybody is arguing. I'm curious why your so intent on keeping the mediocre status quo in place though.


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## Tigger (Oct 8, 2012)

Veneficus said:


> I would argue that ALS can make a difference in trauma.
> 
> In addition to decompressing a tension pneumo, which can be life saving, and ALS provider may not be as apt to over triage to airmed and cost the patient and the system 10s of thousands of dollars.



No doubt this is true, I just see BLS being more worthless on medical calls than trauma. A cab is better half (most of) the time.


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## Brandon O (Oct 9, 2012)

Tigger said:


> No doubt this is true, I just see BLS being more worthless on medical calls than trauma. A cab is better half (most of) the time.



If BLS is worthless to these patients, then so is the triage nurse.


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## Veneficus (Oct 9, 2012)

Brandon Oto said:


> If BLS is worthless to these patients, then so is the triage nurse.



Only if her education does not permit her to be better at it.

All Basic interventions end at "transport to the ED."

The triage nurse has the ability to send somebody back to see the doctor immediately in the ED, have them wait until other patients are taken care of first, and in some institutions, even refer them to fast track or urgent care.

A basic cannot make a patient wait and respond to other calls based on presenting acuity.

A basic cannot refer to anywhere other than the ED.

It is not that I am anti basic, it is that "basics" need to step up their game a lot in today's medicine. Their skills are minimal and some nearly obsolete.


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## Brandon O (Oct 9, 2012)

Veneficus said:


> Only if her education does not permit her to be better at it.
> 
> All Basic interventions end at "transport to the ED."
> 
> The triage nurse has the ability to send somebody back to see the doctor immediately in the ED, have them wait until other patients are taken care of first, and in some institutions, even refer them to fast track or urgent care.



Sure. But just like for an EMT, they're all going to end up seeing the doctor eventually. Likewise, most of an EMT's patients will end up going to the ED, but he can ensure that transport happens at a high or low priority; with ALS intervention, air transport, or other specialty resources; with an appropriate destination hospital which can provide the most appropriate care; with hospital pre-notification of the need for trauma, stroke, or other protocols; and with a transfer of care that allows for the immediate delivery of necessary care and conveys important information that would otherwise have been unavailable. And when patients are reluctant to be transported at all, he can decide how strongly to lean on them and encourage it. He can also advocate for the patient in any number of ways, although that may be beyond the current discussion.



> It is not that I am anti basic, it is that "basics" need to step up their game a lot in today's medicine. Their skills are minimal and some nearly obsolete.



I know we've hashed over this before, and I hate to get into a neverending debate due to terminology. My point is merely that when I say "BLS," I mean this fundamental process of prehospital assessment and the resulting creation of an appropriate plan of care. Even when providing few actual interventions, this is useful stuff. I recognize your point that in practice, most current BLS providers may not have the training to do this very intelligently, but that doesn't mean the concept itself is flawed. Likewise, I appreciate Tigger's emphasis on early palliative measures, and I do wish that those were available at the BLS level, but again, it doesn't invalidate the importance of this process.


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## Veneficus (Oct 9, 2012)

Brandon Oto said:


> Sure. But just like for an EMT, they're all going to end up seeing the doctor eventually. Likewise, most of an EMT's patients will end up going to the ED, but he can ensure that transport happens at a high or low priority; with ALS intervention, air transport, or other specialty resources; with an appropriate destination hospital which can provide the most appropriate care; with hospital pre-notification of the need for trauma, stroke, or other protocols; and with a transfer of care that allows for the immediate delivery of necessary care and conveys important information that would otherwise have been unavailable. And when patients are reluctant to be transported at all, he can decide how strongly to lean on them and encourage it. He can also advocate for the patient in any number of ways, although that may be beyond the current discussion.



I think you considerably overestimate the amount of BLS providers who can do any of this effectively much less efficently.

I agree they should be able to. But should be and are currently have a wide divide.





Brandon Oto said:


> I know we've hashed over this before, and I hate to get into a neverending debate due to terminology. My point is merely that when I say "BLS," I mean this fundamental process of prehospital assessment and the resulting creation of an appropriate plan of care. Even when providing few actual interventions, this is useful stuff. I recognize your point that in practice, most current BLS providers may not have the training to do this very intelligently, but that doesn't mean the concept itself is flawed. Likewise, I appreciate Tigger's emphasis on early palliative measures, and I do wish that those were available at the BLS level, but again, it doesn't invalidate the importance of this process.



I actually think we agree on the concept here, we simply differ on the details.


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## Brandon O (Oct 9, 2012)

Veneficus said:


> I actually think we agree on the concept here, we simply differ on the details.



I think so. The principle and purpose behind BLS care is invaluable. Whether or not most BLS providers are successfully providing this is a different matter.


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## Bullets (Oct 9, 2012)

Veneficus said:


> I think you considerably overestimate the amount of BLS providers who can do any of this effectively much less efficently.
> 
> I agree they should be able to. But should be and are currently have a wide divide.



I agree with your issues regarding BLS, but as i illustrated discussing the NJ pain management at the ALS level, in some systems even those who may have the knowledge and ability simply arent ALLOWED to do this stuff. If i wanted to notify the hospital of a patients condition, i would have to tell my dispatcher what i needed to say and hope that gets relayed accurately, which it rarely ever does. I did the leg work to find the phone numbers to the various "bat phones" at the hospitals in my area, but was always met with suspicion when i asked.

There also seems to be a reluctance in private practice doctors to act as a treatment facility for anything more then the sniffles. I have taken more and more patients out of doctors offices, patients who drove themselves to the office, but now need and ambulance to take them to the hospital for high blood pressure. Or i have had patients RMA and decide to follow up with their PMD only to be called the next day for the same patient. 

If there is a place for BLS in this healthcare world, not only does it require a change at the BLS level,  but also a change in the way Doctors down view their domain. One of the only things it think EMS in NJ has right is that ALS is based and employed by the hospital. This would indicate that the hospitals understand that their services are needed beyond the doors of the physical building and can be brought to the patients home. A patient shouldnt and doesnt have to wait until they are on property to begin recieveing care from the hospital.  Alas that doesnt seem to be the case in most agencies


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## Veneficus (Oct 9, 2012)

Bullets said:


> I agree with your issues regarding BLS, but as i illustrated discussing the NJ pain management at the ALS level, in some systems even those who may have the knowledge and ability simply arent ALLOWED to do this stuff. If i wanted to notify the hospital of a patients condition, i would have to tell my dispatcher what i needed to say and hope that gets relayed accurately, which it rarely ever does. I did the leg work to find the phone numbers to the various "bat phones" at the hospitals in my area, but was always met with suspicion when i asked.
> 
> There also seems to be a reluctance in private practice doctors to act as a treatment facility for anything more then the sniffles. I have taken more and more patients out of doctors offices, patients who drove themselves to the office, but now need and ambulance to take them to the hospital for high blood pressure. Or i have had patients RMA and decide to follow up with their PMD only to be called the next day for the same patient.
> 
> If there is a place for BLS in this healthcare world, not only does it require a change at the BLS level,  but also a change in the way Doctors down view their domain. One of the only things it think EMS in NJ has right is that ALS is based and employed by the hospital. This would indicate that the hospitals understand that their services are needed beyond the doors of the physical building and can be brought to the patients home. A patient shouldnt and doesnt have to wait until they are on property to begin recieveing care from the hospital.  Alas that doesnt seem to be the case in most agencies



I think you are describing 2 seperate problems.

The first is access and payment for care.

The second is a philosophical divide on the purpose of EMS. 

Some years ago, a philosophical divide of the purpose of EMS was established in the US. 

One side was the idea that EMS would be an extension of the hospital and extend the hospital's care to the field. 

On the other was that EMS could never measure the ability of physicians and therefore they should simply rapidly transport patients to the hospital. 

As time goes on it becomes more evident that EMS as an extension of the health system is the only sustainable and valuable role for them. 

Because of the fractured nature of US EMS, what you describe is some places still operating on outdated EMS concepts. 

But it spans the whole divide. There are services embracing successful EMS practices modeled originally by other nations. There are services that are still just a glorified hearse and might as well be a funeral home service and everything in between.

As an interesting bit of trivia, the original idea of extending the hospital to the field was called the Franco-German form of EMS. 

The rapid response and drive to the hospital form was called the US form of EMS. 

The only places that still use the originally "US" idea are parts of the US, developing and underdeveloped nations. 

As emergency medicine EMS fellowships, tactical physician positions, rapid physician response vehicles become more prevalent in the US, I think it is a logical conclusion than a continued shift towards more physician field providers in the US is inevitable.

When you consider that those physicians are best suited to the critical but savable patient populations, it will further marginalize basic EMS providers to more and more transport and less care of acute emergencies. 

As well, when the inevitable changes in reimbursment and malpractice permits more physicians to treat and release, house calls, preventative medicine and the like, the basic EMT will essentially become the rural volunteer or urban  taxi to the most appropriate facility.


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## mycrofft (Oct 9, 2012)

*I liked hogwiley's initial reply*

...because it brings (one of) my pet peeve(s) up; namely, take the toughest poorest slimmest situation and remember that, because we can't all live in the " 'burbs and urbs". 

The reality of the supply of provider candidates, the supply of responders, the supply of equipment and supplies, transport times, numbers and types of cases, must be taken into account before we start cookiecuttering (??) decisions. In many (not most) areas in say NW North America, there is no EMS system as we like to fall back on for our archetypes here. 

ANY training is better than none, not only because of aid rendered, but because you learn what NOT to do, and when to call/send for help. Each level better than basic first aid is an improvement but only if logistics and infrastructure support them, or they are granted some sort of independent duty status...or just go in and do it without any sanctions at all.


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## hogwiley (Oct 9, 2012)

I personally dont care if the EMT Basic certification was eliminated. Like probably everyone here, Ive seen more than a few EMT Basics that scare the crap out of me, and EMS would certainly benefit from having them either go for more training and prove a higher level of competency, or find another job/hobby. 

Im simply pointing out that there is in fact a reason the people who make such decisions have not done so. Mainly the problem is cost. People are only willing to spend so much on EMS, whether we think that is a wise decision or not, its the reality. Having two paramedics on every EMS call everywhere in the US is generally cost prohibitive, and probably has limited value. 

There seems to be a law of EMS that says everyone seems to think the level of training THEY are at should be the minimum level of training. I just find it amusing when newly minted Paramedics who were EMTs for years suddenly decide that we dont need EMTs the minute they become a Paramedic.


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## Bullets (Oct 9, 2012)

Veneficus said:


> As well, when the inevitable changes in reimbursment and malpractice permits more physicians to treat and release, house calls, preventative medicine and the like, the basic EMT will essentially become the rural volunteer or urban  taxi to the most appropriate facility.



And thats fine, if the EMT becomes a true ambulance driver to a Medic and a MD or RN that is a role they can fill. the EMT really would do IFT work and maybe some non-transporting first responder stuff, stop bleeding, start compressions. Most critical care trucks are driven by EMTs around here and are gophers for the ALS crew. 

In cities, most fire chiefs have a driver for their truck, the same could be true of your physician go-teams or something. But as a 911 provider, the training isnt where it needs to be for the EMT to be an effective option. 

Now to get around the politics


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## TransportJockey (Oct 9, 2012)

Bullets said:


> And thats fine, if the EMT becomes a true ambulance driver to a Medic and a MD or RN that is a role they can fill. the EMT really would do IFT work and maybe some non-transporting first responder stuff, stop bleeding, start compressions. Most critical care trucks are driven by EMTs around here and are gophers for the ALS crew.
> 
> In cities, most fire chiefs have a driver for their truck, the same could be true of your physician go-teams or something. But as a 911 provider, the training isnt where it needs to be for the EMT to be an effective option.
> 
> Now to get around the politics



And to be honest, the biggest groups who would oppose this kind of real advancement would be the firefighter unions and the volunteer departments.


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## Veneficus (Oct 9, 2012)

mycrofft said:


> ...because it brings (one of) my pet peeve(s) up; namely, take the toughest poorest slimmest situation and remember that, because we can't all live in the " 'burbs and urbs".



It is not that they can't, it is that many choose not to. Again when you look at the rest of the world, you see concentrated population centers and a very small rural population.

Those rural populations rely on either self sufficency or volunteers. 

The long time rural populations know they cannot expect the same services as the urban populations. They accept when the end has come. 

They do not waste resources on illusion or pretending they have or can afford what their urban counter parts do. 

In the Pacific NW (but not exclusively), you have a phenomenon of people "wanting" to move out of the burbs and urbs without being willing to give up the benefits of social cohabitation. Then they complain they cannot afford to move these services to a small consumer base in an economical way. 

People don't understand, when you choose to isolate yourself, you don't realy get to pick what aspects of isolation you want and those you don't.

Simply, you cannot have your cake and eat it too.  



mycrofft said:


> ...ANY training is better than none, not only because of aid rendered, but because you learn what NOT to do, and when to call/send for help.



I don't think anyone disputes the usefulness or need of a minimally trained provider for out in the sticks. 

But the usefulness of the EMT-B in other environments comes down to being cheaper than a medic or totally out of their element. What is the point of paying for an EMT and all the emergency equipment on a BLS ambulance for the dialysis derby?

The only part of EMt-B training applicable is the ability to take a set of vitals. Even that is disputable as it other even lesser trained providers can do the same at a fraction of the cost.

The reason it takes an ambulance at all is because somebody makes a lot of money for charging medicare/medicade for "medical transport" when a simple taxi with a cot and 2 orderlies would do.

How much do you think you would have to pay 2 untrained laborers to pick somebody up, put them on a cot, and drive them anywhere they needed or wanted to go at any given time?


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## NYMedic828 (Oct 9, 2012)

Veneficus said:


> How much do you think you would have to pay 2 untrained laborers to pick somebody up, put them on a cot, and drive them anywhere they needed or wanted to go at any given time?



$5 for the first mile and $1.50 for every mile after that.


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## Veneficus (Oct 9, 2012)

NYMedic828 said:


> $5 for the first mile and $1.50 for every mile after that.



Exactly.

Saves a lot of money carting the dialysis patient 3 times a week at the BLS rate. Imagine the savings over a year across the US.


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## NYMedic828 (Oct 9, 2012)

Veneficus said:


> Exactly.
> 
> Saves a lot of money carting the dialysis patient 3 times a week at the BLS rate. Imagine the savings over a year across the US.



Especially considering the cost of their transport and treatment from the receiving facility partially comes out of my own paycheck... Yayyy liberalism.


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## 11569150 (Oct 9, 2012)

I would just like to point out that there are places in rural US that are still entirely bls volunteer ambulance services.  I would like to use covelo, ca as an example: it is an hour and a half drive to the nearest town from there let alone to the nearest hospital and als ambulance. The folks up there are mostly dope growers and natives.  Handfuls of ambulance companies have looked at staffing that town but no one will touch it because its so secluded.  They usually rely on air transport if the weather is nice other than that hour plus als rendezvous.  Now, doing away with the emt-b cert entirely would mean the FD would have to figure out a way to motivate their volunteers into taking expensive classes that are hours away and all for something that they get no financial reimbersment for in the first place.  Covelo is lucky to even have the service they have right now and forcing bls out of the picure would just elimate healthcare there entirely.  Just saying something to think about.


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## NYMedic828 (Oct 9, 2012)

11569150 said:


> I would just like to point out that there are places in rural US that are still entirely bls volunteer ambulance services.  I would like to use covelo, ca as an example: it is an hour and a half drive to the nearest town from there let alone to the nearest hospital and als ambulance. The folks up there are mostly dope growers and natives.  Handfuls of ambulance companies have looked at staffing that town but no one will touch it because its so secluded.  They usually rely on air transport if the weather is nice other than that hour plus als rendezvous.  Now, doing away with the emt-b cert entirely would mean the FD would have to figure out a way to motivate their volunteers into taking expensive classes that are hours away and all for something that they get no financial reimbersment for in the first place.  Covelo is lucky to even have the service they have right now and forcing bls out of the picure would just elimate healthcare there entirely.  Just saying something to think about.



Or as Vene stated, just have two untrained regular joes drive them to the hospital. They can still be volunteer fireman they don't need EMS training.

For an hour and a half ride what is an EMT going to do other than take vitals 100 times and give O2 which probably isn't even indicated for the condition let alone the length of time it would be on the patient for. Even if the patient degraded enroute an EMT can still only provide CPR and ventilate which is a futile effort that far from a hospital and CPR training is widespread and far less costly than EMT b.


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## TransportJockey (Oct 9, 2012)

11569150 said:


> I would just like to point out that there are places in rural US that are still entirely bls volunteer ambulance services.  I would like to use covelo, ca as an example: it is an hour and a half drive to the nearest town from there let alone to the nearest hospital and als ambulance. The folks up there are mostly dope growers and natives.  Handfuls of ambulance companies have looked at staffing that town but no one will touch it because its so secluded.  They usually rely on air transport if the weather is nice other than that hour plus als rendezvous.  Now, doing away with the emt-b cert entirely would mean the FD would have to figure out a way to motivate their volunteers into taking expensive classes that are hours away and all for something that they get no financial reimbersment for in the first place.  Covelo is lucky to even have the service they have right now and forcing bls out of the picure would just elimate healthcare there entirely.  Just saying something to think about.



There are areas here in NM that manage coverage for areas like that at the ALS level. Texas had areas like that with ALS coverage too. So I'm not seeing the problem. It's just an issue with looking at it as a county wide thing rather than one podunk town seperate from the county


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## Jambi (Oct 9, 2012)

11569150 said:


> Now, doing away with the emt-b cert entirely would mean the FD would have to figure out a way to motivate their volunteers into taking expensive classes that are hours away and all for something that they get no financial reimbersment for in the first place.  Covelo is lucky to even have the service they have right now and forcing bls out of the picure would just elimate healthcare there entirely.  Just saying something to think about.



This notion discounts distance education with periodic travel for in-class instruction and skill competency practice.  Delivering AEMT would be trivial with this method and the associated cost would be far lower than that fancy piece of apparatus that gets washed, waxed, and polished far more often than it goes on medical aids.


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## Veneficus (Oct 9, 2012)

11569150 said:


> I would just like to point out that there are places in rural US that are still entirely bls volunteer ambulance services.



I think there is an important discussion here so I will spin it off as another thread.


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## Brandon O (Oct 9, 2012)

Veneficus said:


> The only part of EMt-B training applicable is the ability to take a set of vitals.



I would give up the ability to take vital signs (i.e. the numbers -- not the overall physical exam) before I'd give up many other portions of my assessment.


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## hogwiley (Oct 10, 2012)

NYMedic828 said:


> Or as Vene stated, just have two untrained regular joes drive them to the hospital. They can still be volunteer fireman they don't need EMS training.
> 
> For an hour and a half ride what is an EMT going to do other than take vitals 100 times and give O2 which probably isn't even indicated for the condition let alone the length of time it would be on the patient for. Even if the patient degraded enroute an EMT can still only provide CPR and ventilate which is a futile effort that far from a hospital and CPR training is widespread and far less costly than EMT b.



Ok, so now the argument has gone from EMTs dont have enough training, to EMTs have too much expensive time consuming training? Well which is it. 

You basically made the same friggin argument that I did, that it doesnt take a PHD to drive an ambulance, so whats the point in having 2 medics on every 911 call, or delaying transport substantially because you insist on every responder and ambulance driver being a Paramedic.


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## Veneficus (Oct 10, 2012)

Brandon Oto said:


> I would give up the ability to take vital signs (i.e. the numbers -- not the overall physical exam) before I'd give up many other portions of my assessment.



Have you taken an actual pathophys class yet?


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## Veneficus (Oct 10, 2012)

hogwiley said:


> Ok, so now the argument has gone from EMTs dont have enough training, to EMTs have too much expensive time consuming training? Well which is it.
> 
> You basically made the same friggin argument that I did, that it doesnt take a PHD to drive an ambulance, so whats the point in having 2 medics on every 911 call, or delaying transport substantially because you insist on every responder and ambulance driver being a Paramedic.



A bit of both I think.

They don't have enough training to really be effective, they have too much for what they are actually doing.


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## NYMedic828 (Oct 10, 2012)

hogwiley said:


> Ok, so now the argument has gone from EMTs dont have enough training, to EMTs have too much expensive time consuming training? Well which is it.
> 
> You basically made the same friggin argument that I did, that it doesnt take a PHD to drive an ambulance, so whats the point in having 2 medics on every 911 call, or delaying transport substantially because you insist on every responder and ambulance driver being a Paramedic.



Because you should either do things properly and have a capable provider on the ambulance to provide actual emergency care or you should have an untrained taxi driver at minimum wage.

This in-between thing is getting old, costly, and pointless.

And for the record, you aren't delaying transport if the initial ambulance is already ALS... don't have to wait for anyone...


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## mycrofft (Oct 10, 2012)

So we need the ability to have paramedics or higher available in case, but EMT-B's are more efficient and prevalent.
Welcome to the crux of the issue in emergency preparedness; how can you balance preparing for the maximum foreseeable need versus the everyday?
I still think the paradigm of a federal or state service providing this makes more sense. People would be rotated in and out of backwaters where some of their skills would atrophy and in and out of inner city  areas where their skills could be challenged more in other aspects. Maybe four years service like that, then earning higher rank/education get a more-permanent assignment...sort of like the military used to be. Heck, give them a GI Bill of sorts. And employ veterans preferentially.


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## mycrofft (Oct 10, 2012)

So we need the ability to have paramedics or higher available in case, but EMT-B's are more efficient and prevalent.

Welcome to the crux of the issue in emergency preparedness; how can you balance preparing for the maximum foreseeable need versus the everyday?

I still think the paradigm of a federal or state service providing this makes more sense. People would be rotated in and out of backwaters where some of their skills would atrophy and in and out of inner city  areas where their skills could be challenged more in other aspects. Maybe four years service like that, then earning higher rank/education get a more-permanent assignment...sort of like the military used to be. Heck, give them a GI Bill of sorts. And employ veterans preferentially.


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## Brandon O (Oct 10, 2012)

Veneficus said:


> Have you taken an actual pathophys class yet?



Have you practiced the bassoon today? Why are we getting personal here?


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## Veneficus (Oct 10, 2012)

mycrofft said:


> So we need the ability to have paramedics or higher available in case, but EMT-B's are more efficient and prevalent.
> 
> Welcome to the crux of the issue in emergency preparedness; how can you balance preparing for the maximum foreseeable need versus the everyday?
> 
> I still think the paradigm of a federal or state service providing this makes more sense. People would be rotated in and out of backwaters where some of their skills would atrophy and in and out of inner city  areas where their skills could be challenged more in other aspects..



This type of system set up is already employed and works well. 

Where I have seen it, there is no way to get out of the rotation. 

After a while, there would be a bottleneck of senior guys in prefered positions while the younger ones were getting burned out in the less desirable ones. 

Everyone rotates, no exceptions, is the best way I think.


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## 18G (Oct 10, 2012)

I have thought for a long time that EMT-Basic should not be allowed to be a primary care provider on an ambulance. The skill set and knowledge is too limited for what is needed and expected today. 

While I would like to see the current Paramedic level become the minimum required, I know that will likely never happen on a national level. AEMT from what I have seen is many times better than EMT-Basic. The AEMT has the ability to directly intervene and improve a patients condition and symptoms.


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## TransportJockey (Oct 10, 2012)

18G said:


> I have thought for a long time that EMT-Basic should not be allowed to be a primary care provider on an ambulance. The skill set and knowledge is too limited for what is needed and expected today.
> 
> While I would like to see the current Paramedic level become the minimum required, I know that will likely never happen on a national level. AEMT from what I have seen is many times better than EMT-Basic. The AEMT has the ability to directly intervene and improve a patients condition and symptoms.



Sorta like how Georgia seems to be... To work on An ambulance most services require minimum of AEMT. Basics have no business being primary on a truck. I fully agree with you. But then again I also think that Oregon has the right idea with a mandatory AAS minimum for medics. Rumor has it NM is going that way soon


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## mycrofft (Oct 10, 2012)

Canada's first aid laws take distance to/from urban settings as a factor. DO their EMS laws also do that?


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## hogwiley (Oct 10, 2012)

18G said:


> I have thought for a long time that EMT-Basic should not be allowed to be a primary care provider on an ambulance. The skill set and knowledge is too limited for what is needed and expected today.
> 
> While I would like to see the current Paramedic level become the minimum required, I know that will likely never happen on a national level. AEMT from what I have seen is many times better than EMT-Basic. The AEMT has the ability to directly intervene and improve a patients condition and symptoms.



This seems reasonable to me, but it seems like EMT specialists are a dying breed. Not sure why, but very few(if any) schools offer this type of training any more. 

EMT-I's are kind of the LPNs of EMS. Hospitals prefer to just have RNs aided by CNAs, just as most EMS agencies have Paramedics partnered with Basics. I dont see CNAs being done away with any time soon, and I dont see EMT Basics disappearing. If anything is going to disappear itll be the LPNs and the EMT-I/AEMT because they cant do all the things RNs/Paramedics do, but their training is still fairly time consuming and expensive, making them cost prohibitive as just assistants or ambulance drivers.


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## Rialaigh (Oct 10, 2012)

hogwiley said:


> This seems reasonable to me, but it seems like EMT specialists are a dying breed. Not sure why, but very few(if any) schools offer this type of training any more.
> 
> EMT-I's are kind of the LPNs of EMS. Hospitals prefer to just have RNs aided by CNAs, just as most EMS agencies have Paramedics partnered with Basics. I dont see CNAs being done away with any time soon, and I dont see EMT Basics disappearing. If anything is going to disappear itll be the LPNs and the EMT-I/AEMT because they cant do all the things RNs/Paramedics do, but their training is still fairly time consuming and expensive, making them cost prohibitive as just assistants or ambulance drivers.



This. I see no need to have an EMT-I or an AEMT. Frankly if I code or one of my family members crashes I want someone who is trained to at least a medic level showing up.....no need to dumb down an undertrained (in general) even more. 

It basically boils down to...if a person doesn't want to give up 18 months to go to class do we really want them to be the highest common pre-hospital care you will be receiving....it's kind of a joke..

I see a place for EMT-B and frankly wish they would *make IV access a basic skill* so that while the medic is trying to get a feel for the patients injuries the basic can start towards the single most important thing on critical calls which most of the time is going to be IV access...if basics stayed exactly the same but could gain IV access they would be so much more useful.


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## Veneficus (Oct 10, 2012)

Rialaigh said:


> This. I see no need to have an EMT-I or an AEMT. Frankly if I code or one of my family members crashes I want someone who is trained to at least a medic level showing up.....no need to dumb down an undertrained (in general) even more.



I'd rather have a bystander with an AED who will perform cpr. 



Rialaigh said:


> I see a place for EMT-B and frankly wish they would *make IV access a basic skill* so that while the medic is trying to get a feel for the patients injuries the basic can start towards the single most important thing on critical calls which most of the time is going to be IV access...if basics stayed exactly the same but could gain IV access they would be so much more useful.



I am very proud of my IV skills, but to call it the single most important thing I would say is severely overstating it's value.


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## Rialaigh (Oct 10, 2012)

Veneficus said:


> I'd rather have a bystander with an AED who will perform cpr.
> 
> 
> 
> I am very proud of my IV skills, but to call it the single most important thing I would say is severely overstating it's value.



Id rather have a bystander too, but to think that an EMT-I or a AEMT can replace paramedics in a pre hospital setting is just a terrible idea


As far as the IV thing goes. Name one single other skill that you would rather have a Basic learn. Just one skill...IV access would seem to be one of the most important things a pre-hospital team can do to provide relief for patients in life threatening situations. It however is probably the single most important thing it can do to provide an easy continuum of care into the hospital setting to allow for the most rapid treatment of the patient once reaching a hospital. 

In a hospital (here at least) when you roll through the door if you don't have a BP in the last 10 minutes they might say why, but the fact is they will retake one before they do anything (therefore you have not delayed PT care). If you have evaluated the patient mentally they will be happy, but they will do it again before they do anything (therefore whether you do it you have not delayed pt care). But if you have not placed a IV yet and pushed meds per protocol (and more importantly using a good educational background) then you have delayed patient care whether its a slower time to pain relief or a slower time to lowering a high BP. 


I was wrong to say it was the single most important thing in a pre-hospital setting. I may be more right to say it is the most helpful single skill that could be added on to a basics training with ease.


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## Veneficus (Oct 10, 2012)

Rialaigh said:


> Id rather have a bystander too, but to think that an EMT-I or a AEMT can replace paramedics in a pre hospital setting is just a terrible idea



I agree.

Mostly because it perpetuates skills based providers instead of knowledge based ones.

In the modern world, skill based EMS is simply not effective and not worth paying for.



Rialaigh said:


> As far as the IV thing goes. Name one single other skill that you would rather have a Basic learn. Just one skill...



The ability to take a proper history andperform a physical exam that is more than an easily remembered acronym that is so basc it basically gives no info at all.



Rialaigh said:


> IV access would seem to be one of the most important things a pre-hospital team can do to provide relief for patients in life threatening situations.



I respectfully disagree.

Code drugs are basically BS. 

Fluid therapy for massive hemorrhage has been reduced in favor of permissive hypotension.

In anaphylaxis, IM is the prefered epi route.

In hypoglycemia there is not only IM glucagon, which carries much less risk than extravasiation of d50, but also buccal and sublingual glucose.

In the US for respiratory emergencies requiring B agonists, nebulized is preferred over IV. 

Midazolam and diazepam can be given IN and rectally respectively. (much easier than starting a line on a seizing patient.)

Furosimide is being steadily removed for CHF exacerbation around the world in the prehospital environment.

Did you have another life threatening emergency in mind that isn't better helped with a mechanical or electrical device?



Rialaigh said:


> It however is probably the single most important thing it can do to provide an easy continuum of care into the hospital setting to allow for the most rapid treatment of the patient once reaching a hospital.



What about in the growing number of institutions that are imediately DCing prehospital lines and starting their own fr fear of not being reimbursed for "treatment relating to preventable complications" in the US?



Rialaigh said:


> In a hospital (here at least) when you roll through the door if you don't have a BP in the last 10 minutes they might say why, but the fact is they will retake one before they do anything (therefore you have not delayed PT care). If you have evaluated the patient mentally they will be happy, but they will do it again before they do anything (therefore whether you do it you have not delayed pt care).



Because they are looking for change over time?



Rialaigh said:


> But if you have not placed a IV yet and pushed meds per protocol (and more importantly using a good educational background) then you have delayed patient care whether its a slower time to pain relief or a slower time to lowering a high BP.



Does that include IN fent or SL nitro or nitro paste?

Perhaps if you are using lebatalol you need the IV, but I can count on one hand the number of times I have used that in my career. At least one of those times it wasn't really needed, but verbal orders are verbal orders, and ever since discovering esmolol I would choose that over labetalol any day. 
(wh is carrying that on the truck?)



Rialaigh said:


> I was wrong to say it was the single most important thing in a pre-hospital setting. I may be more right to say it is the most helpful single skill that could be added on to a basics training with ease.



I agree.


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## Rialaigh (Oct 10, 2012)

Veneficus said:


> I agree.
> 
> Mostly because it perpetuates skills based providers instead of knowledge based ones.
> 
> ...




I have never seen or been in a hospital that dc's pre-hospital lines only to start their own.

My point with it being the most valuable thing a basic could easily learn is that sure a thorough history is great, and will be repeated upon arrival to er. A 12 lead is great, and will be repeated upon arrival to the er. etc..etc..etc..it doesn't matter what you do or what you find out in an ambulance it will be completely repeated upon arrival to the ER. 

One of the few things that EMS does that hospitals "continue" with instead of redoing is placing IV lines. It is one of the few things that legitimately saves time for the ER staff and allows for a reduced amount of time between patient arrival to the ER and medication of the patient.


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## TransportJockey (Oct 10, 2012)

Rialaigh said:


> I have never seen or been in a hospital that dc's pre-hospital lines only to start their own.
> 
> My point with it being the most valuable thing a basic could easily learn is that sure a thorough history is great, and will be repeated upon arrival to er. A 12 lead is great, and will be repeated upon arrival to the er. etc..etc..etc..it doesn't matter what you do or what you find out in an ambulance it will be completely repeated upon arrival to the ER.
> 
> One of the few things that EMS does that hospitals "continue" with instead of redoing is placing IV lines. It is one of the few things that legitimately saves time for the ER staff and allows for a reduced amount of time between patient arrival to the ER and medication of the patient.


Around here every hospital pulls field lines and since they are drawing their labs they just use an iv cath instead of a butterfly.


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## Aidey (Oct 10, 2012)

Rialaigh said:


> I have never seen or been in a hospital that dc's pre-hospital lines only to start their own.
> 
> My point with it being the most valuable thing a basic could easily learn is that sure a thorough history is great, and will be repeated upon arrival to er. A 12 lead is great, and will be repeated upon arrival to the er. etc..etc..etc..it doesn't matter what you do or what you find out in an ambulance it will be completely repeated upon arrival to the ER.



12 leads are repeated for several reasons, one of them being so that the hospital can compare them and look for changes. Serial 12 leads are practice for a reason.


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## JPINFV (Oct 11, 2012)

Rialaigh said:


> As far as the IV thing goes. Name one single other skill that you would rather have a Basic learn. Just one skill...



Patient assessment would be one place to start.


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## Rialaigh (Oct 11, 2012)

JPINFV said:


> Patient assessment would be one place to start.



Which is already a taught basic skill. Now we can debate the quality of education but a patient assessment is supposed to be taught and passed prior to earning EMT-B


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## Rialaigh (Oct 11, 2012)

Aidey said:


> 12 leads are repeated for several reasons, one of them being so that the hospital can compare them and look for changes. Serial 12 leads are practice for a reason.



I understand the usefulness of them. It is the same as vital sign trends and lab trends. I am not saying these other things cannot be useful. I am saying that starting an IV line would be helpful, time saving, and useful on at least 80% of calls. You really can't say that about most other interventions that Basics don't know right now.


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## Rialaigh (Oct 11, 2012)

TransportJockey said:


> Around here every hospital pulls field lines and since they are drawing their labs they just use an iv cath instead of a butterfly.



Wow...honestly this sounds like nothing more than a needless increased risk of infection. I see a few positives to doing this with a lot more negatives. If you can't trust an EMS field line than you shouldn't be having medics start lines in the field anyway.


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## Veneficus (Oct 11, 2012)

Rialaigh said:


> Which is already a taught basic skill. Now we can debate the quality of education but a patient assessment is supposed to be taught and passed prior to earning EMT-B



Unfortunately, what is taught is only a shadow of a patient assessment.

The important limit to consider is it teaches how to look for life threatening conditions that largely do not exist anymore because of the evolution of the diseases we suffer from.

Anyone who truly understand patient assessment knows it cannot be done without knowledge of physiology and pathophysiology. 

Sadly because of this outdated Basic approach, it is easy to overlook very sick people or people who would benefit from medical attention.



Rialaigh said:


> I understand the usefulness of them. It is the same as vital sign trends and lab trends. I am not saying these other things cannot be useful. I am saying that starting an IV line would be helpful, time saving, and useful on at least 80% of calls. You really can't say that about most other interventions that Basics don't know right now.



I am not sure 80% of patients EMS sees even need IVs at all. 



Rialaigh said:


> Wow...honestly this sounds like nothing more than a needless increased risk of infection. I see a few positives to doing this with a lot more negatives. If you can't trust an EMS field line than you shouldn't be having medics start lines in the field anyway.



It is not so simple. The major driving force is the money.

Medicare has mandated that care needed from "preventable" complications will no longer be paid for. Which means in the unlikely chance of a phlebitis, extravasiation, or even a worst case scenario of sepsis, the hospital is going to eat all the costs of that unless they can show they did everything possible to prevent it from the needlestick. 

Hospitals do have control over their employees, procedures, and environment. They cannot exercise that control over non-hospital based EMS employees, their procedures, or their environment.

Recall that in the ICU, especially peds and NICU, insertion of an IO needle is a steril procedure. This is specifically to cut down on infection. Which means, if you start an IO in the field, once that patient gets to the unit, it will certainly be pulled. 

In the unlikely event they devide to replace it instead of using another more advantageous method of vessel monitoring and access, it will be under sterile conditions.


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## Jambi (Oct 11, 2012)

Rialaigh said:


> Which is already a taught basic skill. Now we can debate the quality of education but a patient assessment is supposed to be taught and passed prior to earning EMT-B



If you were to read the thread at the end of that link you'd see that while it may be "taught" as a basic skill, it's not really taught as a truly meaningful skill outside of "ABCs and something is wrong."

It's not a dig at EMT's.  It is a dig at the state of the profession, at all levels, and as a paramedic, and a long-time EMT educator I feel comfortable in make such statements.


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## escherichiaColi0157 (Oct 11, 2012)

I have been an EMT-B for 13 years. I work with an 19 year veteran paramedic and she states she would  trusts the basics to do the 'basics' better than her fellow medics. The paramedics tend to rely on their technology; treating the ECG display rather than the patient and the like. All that aside, why do we act like EMT's and paramedics are two rival football teams instead of two groups working on the same team toward the same goal-patient care?


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## NYMedic828 (Oct 11, 2012)

escherichiaColi0157 said:


> I have been an EMT-B for 13 years. I work with an 19 year veteran paramedic and she states she would  trusts the basics to do the 'basics' better than her fellow medics. The paramedics tend to rely on their technology; treating the ECG display rather than the patient and the like. All that aside, why do we act like EMT's and paramedics are two rival football teams instead of two groups working on the same team toward the same goal-patient care?



A basic being better at basics than the medic is the fault of the service employing poor medics.

The reason this discussion constantly presents itself is because one of the two is already obsolete and the other is quickly following. The current EMS system cannot sustain itself much longer in the current economy and state of medicine. It must advance indefinitely or be left for dead.


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## mycrofft (Oct 11, 2012)

It OUGHT to evolve or die, but it will not because there is no alternative. The DRAWBACK to civil services is that, since private companies already have no true interest in providing the same or better service, there IS no parallel track of evolution. The fact that it took the NHTSA to create EMS, and not the Dept of Health or AMA, is a rare example of damning the torpedoes and squaring away a problem.

As for paramedics who can't put on bandaids, try surgeons ("to cut is to curve") versus internists ("a pill for every ill"). When you get handed the big hammers, the little ones get neglected, but every job requires a hammer....so many ruined screws that way.


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## Veneficus (Oct 11, 2012)

escherichiaColi0157 said:


> I have been an EMT-B for 13 years. I work with an 19 year veteran paramedic and she states she would  trusts the basics to do the 'basics' better than her fellow medics. The paramedics tend to rely on their technology; treating the ECG display rather than the patient and the like. All that aside, why do we act like EMT's and paramedics are two rival football teams instead of two groups working on the same team toward the same goal-patient care?



Finally, an easy question...

Because EMTs dn't have patient care as the goal. They have ease of entry, minimum qualifications, absense of responsibility and decision making, and not changing what they have done for the last 40 years despite astonishing strides in medicine as the goal.

Modern paramedics (with the exceptin of the old dinosaurs still preaching they don't diagnose and lack clinical decsion making authority despite protocols that actually spell out they do) are attempting to become a recognized healthcare provider of professional status that has clinical decision making capability along with adding value beyond a taxi ride to the ED in order to increase their social status and pay.

The patient is unfortunately caught in the middle. This same game was played in the past when surgeons started being required to go to medical school. Going from the pay and prestige of the local vocational barber to some of the most prestigious and well payed doctors did seem to work out for them in the end.

(Medical trivia, did you know the modern residency of physicians exists because it was part of the compromise when surgeons were first required to go to medical school and were adamante they would not accept medical education in an academic institution could possibly produce a surgeon that was equal to a multi year apprenticeship?)


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## escherichiaColi0157 (Oct 11, 2012)

I am shocked at your statements that EMT's have, "Absence of responsibility and decision making," AND do not have patient care as a goal. Gee, what IS their goal then? Wow, you have got to be kidding. Ever consider SAR EMT's? Or Wilderness EMT's or lifeguards? maybe you're thinking of your transport only basics but there are  basic's providing patient care in backcountry and extreme wilderness making limb and life decisions many paramedics will never be exposed to in their clean rigs. Trust me, I respect the knowledge and additional training of the medic, but not their ego trips.


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## Jambi (Oct 11, 2012)

escherichiaColi0157 said:


> ...but there are  basic's providing patient care in backcountry and extreme wilderness making limb and life decisions many paramedics will never be exposed to in their clean rigs...



Examples?


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## Tigger (Oct 11, 2012)

escherichiaColi0157 said:


> I am shocked at your statements that EMT's have, "Absence of responsibility and decision making," AND do not have patient care as a goal. Gee, what IS their goal then? Wow, you have got to be kidding. Ever consider SAR EMT's? Or Wilderness EMT's or lifeguards? maybe you're thinking of your transport only basics but there are  basic's providing patient care in backcountry and extreme wilderness making limb and life decisions many paramedics will never be exposed to in their clean rigs. Trust me, I respect the knowledge and additional training of the medic, but not their ego trips.



The goal would be to get the patient to a hospital where they can receive care. Care as in something more than placing the  patient a backboard and holding their hand.


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## Jambi (Oct 11, 2012)

escherichiaColi0157 said:


> Trust me, I respect the knowledge and additional training of the medic, but not their ego trips.



You may respect what you wish, but I offer the following information...do with it what you will.

1. How many hours are needed to qualify to take the State Board examinations?
Cosmetologist = 1600 hours, Barber = 1500 hours, Esthetician = 600 hours, Electrologist = 600 hours, Manicurist = 400 hours.
http://www.barbercosmo.ca.gov/forms_pubs/faqs.shtml#ae1

versus...

To be eligible for a paramedic license in California an individual must:
•	successfully complete an approved paramedic training program;  

The minimum number of hours required for training is 1,090:
	Didactic and skills				           450 hours
	Hospital and clinical training			           160 hours
	Field internship					           480 hours
(which must include a minimum of 40 advanced life support (ALS) patient contacts)
http://www.emsa.ca.gov/paramedic/files/FrequentlyAskedQuestionsRevAug2012.rtf

and for EMT

• 120 hours total
• ≈ 110 hours
didactic
• ≈ 10 hours clinical
http://www.emsa.ca.gov/pubs/pdf/EMSA131.pdf


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## rescue1 (Oct 11, 2012)

escherichiaColi0157 said:


> I am shocked at your statements that EMT's have, "Absence of responsibility and decision making," AND do not have patient care as a goal. Gee, what IS their goal then? Wow, you have got to be kidding. Ever consider SAR EMT's? Or Wilderness EMT's or lifeguards? maybe you're thinking of your transport only basics but there are  basic's providing patient care in backcountry and extreme wilderness making limb and life decisions many paramedics will never be exposed to in their clean rigs. Trust me, I respect the knowledge and additional training of the medic, but not their ego trips.



I'm not sure if a "making a life or limb decision" is even within the scope of practice for a basic.


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## NYMedic828 (Oct 11, 2012)

escherichiaColi0157 said:


> I am shocked at your statements that EMT's have, "Absence of responsibility and decision making," AND do not have patient care as a goal. Gee, what IS their goal then? Wow, you have got to be kidding. Ever consider SAR EMT's? Or Wilderness EMT's or lifeguards? maybe you're thinking of your transport only basics but there are  basic's providing patient care in backcountry and extreme wilderness making limb and life decisions many paramedics will never be exposed to in their clean rigs. Trust me, I respect the knowledge and additional training of the medic, but not their ego trips.



Quite often I find that the "ego trip" opinion arises from one of two factors. 1, the paramedic is incompetent and hides it via harsh attitude. 2, more common, the accuser is incompetent or feels inferior and tries to hide it or justify themselves by raising their own pedestal.

Wilderness EMTs are basically capable of the same thing as anyone else. Transport to a hospital. They still can not perform any actual emergent procedures.

Also, assuming your comment is in relation to Vene's post, realize that Vene has earned the right to preach what he wants whether you agree with it or not. His "training" buries yours by 15+ years of schooling...


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## mycrofft (Oct 11, 2012)

escherichiaColi0157 said:


> I am shocked at your statements that EMT's have, "Absence of responsibility and decision making," AND do not have patient care as a goal. Gee, what IS their goal then? Wow, you have got to be kidding. Ever consider SAR EMT's? Or Wilderness EMT's or lifeguards? maybe you're thinking of your transport only basics but there are  basic's providing patient care in backcountry and extreme wilderness making limb and life decisions many paramedics will never be exposed to in their clean rigs. Trust me, I respect the knowledge and additional training of the medic, but not their ego trips.



The EMT part is supposed to follow protocols. The SAR, Tactical, or whatever part is a whole 'nother world. Those issues are not medical ones, although they impact the medical aspects.

I think folks get that point but the hyperbole puts them off.


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## mycrofft (Oct 11, 2012)

rescue1 said:


> I'm not sure if a "making a life or limb decision" is even within the scope of practice for a basic.



Of course EMT's make life or limb decisions, but the path to follow to do that is supposed to be covered by a protocol. 

And theoretically when you get enough protocols every possible situation is covered.:rofl:

The decision to stay and treat versus treat enroute is one such decision, the decision to open an airway with OPA or by patient positioning can be another. The big one is deciding when the protocol doesn't make sense, and alternative "diagnoses" must be entertained or the protocols bypassed for cause.


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## hogwiley (Oct 11, 2012)

Veneficus said:


> Finally, an easy question...
> 
> Because EMTs dn't have patient care as the goal. They have ease of entry, minimum qualifications, absense of responsibility and decision making, and not changing what they have done for the last 40 years despite astonishing strides in medicine as the goal.



I dont really disagree with this statement, however it really isnt the EMTs fault. Most people when they go to school to be an EMT, assume they are taking on a lot of responsibility, that the school will be difficult and have high standards and that their decision making ability is crucial and will be put to the test. Like most people, I didnt even know paramedic and EMT were different things. It isnt until most of the way through EMT school that the student begins to realize that hey, this stuff really isnt that hard, and its the Paramedics who have the real responsibility, but its not like you can blame the EMT for that. 

There seems to be this notion that people who dont immediately go to Paramedic school are somehow stupid, or lazy, or just want the minimum standards, yet MOST paramedics didnt go right from EMT school to Paramedic school. Most worked as EMTs, sometimes for years, and many of them(the honest ones) will say that working as an EMT made Paramedic school less stressful and working as a brand new Paramedic less difficult. 

The ones who say EMT experience makes no difference in Paramedic school are simply wrong. The pass rate for students with EMT experience is significantly higher than it is for those with no experience, and Ive personally seen those medics who did pass with no experience struggily mightily as brand new Paramedics, versus the ones with EMT experience who had a far smoother transition.


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## NYMedic828 (Oct 11, 2012)

Most people wait to go to medic school because they are set in their lives or simply can't afford it.

$10,000 is a lot to come up with on such low wages. Not to mention the vocational schooling is not covered under any student loan programs. At least not here it isn't. It has to come out of pocket or a regular loan.

Having initial experience helps but only because it increases your comfort level in communicating with patients. Everything else is a waste of time.


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## triemal04 (Oct 11, 2012)

escherichiaColi0157 said:


> I am shocked at your statements that EMT's have, "Absence of responsibility and decision making," AND do not have patient care as a goal. Gee, what IS their goal then? Wow, you have got to be kidding. Ever consider SAR EMT's? Or Wilderness EMT's or lifeguards? maybe you're thinking of your transport only basics but there are  basic's providing patient care in backcountry and extreme wilderness making limb and life decisions many paramedics will never be exposed to in their clean rigs. Trust me, I respect the knowledge and additional training of the medic, but not their ego trips.


Calm down for a minute.  This type of knee-jerk hyperbole filled reaction is why conversations along these lines never go anywhere, and why certain people's opinions of EMT's continues to be low/go lower.

It's not that EMT's don't have patient care as a goal, it's that their definition of patient care is very, very, very low.  (as is a paramedic's, depending on the situation/location and who you are comparing them to)  In all actuallity there is very little that an EMT can do for a patient to change their overall mortality and outcome from their current problem beyond driving them to a hospital; ie "higher medical care."  Couple that with how little EMT's are actually taught about disease's, injuries, pathophysiology, anatomy and physiology and you should be able to start to see *why* their level of care is so low, and *why *their ultimate goal is to get the patient to someone who understands those things.

Leaving out the hyperbole about a very small subset of EMT's, then yes, there aren't that many decisions that the average EMT will make regarding the care of a patient.  While there are still some to be made, as far as medical treatements and care go...not a lot of autonomy.

For the 3 groups that you mentioned...even they don't do much.  And the vast majority of services that they do provide have much less to do with their training and education as an EMT than with whatever else they are required to know.  Add in that it's not just EMT's that function is those roles and that many, many paramedics have to make decisions outside "their clean rigs" in very austere environments...invalid arguement.

In the grand scheme of medicine, EMT's do almost nothing of vital importance.  (wether or not the average paramedic does is also debatable)  It isn't a slam on EMT's or an insult...it's just being honest.  Most EMT's *don't* make very critical decisions.  Most EMT's *don't* have to make medically oriented decisions on their own.  Most EMT's *won't* effect a patient's outcome.  Sad but true.

If you really have been an EMT for 13 years, don't have a chip on your shoulder, have a decent understanding of what healthcare and medicine are and how they work, and understand what it is that EMS does, then none of this should be news...and it shouldn't be upsetting you.


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## Veneficus (Oct 11, 2012)

escherichiaColi0157 said:


> I am shocked at your statements that EMT's have, "Absence of responsibility and decision making," AND do not have patient care as a goal.


Why is this statement shocking to you?

Do you have a license or a certification? Can you practice without the  authority of a medical control physician? Is that physician not ultimately responsible for the care you provide? Does that physician not exclusively determine what you can or cannot do? If your protocol dictates you must perform a specific intervention and you follow such, if harm comes to the patient from it are you held accountable or your physician medical director?

(i'll admit somebody might try to make you the scapegoat, but your defense is still going to be "I was following protocol.")

If you actually had patient care as the goal, EMTs and infact all of EMS would be demanding that educational standards meet the demands of today's medicine. As of this moment, the opposite is true.

If you actually had patient care as the goal there would be a demand of the rank and file to abandon harmful and useless practices and institute interventions that are beneficial in today's world. 

Let's not pretend we are anywhere near that.

The EMT has 2 endpoints to patient care and both of them revolve around passing that patient off. Either to ALS or to a hospital.

What you tell girls or guys at parties is your business.

But the fact is anyone who can do compressions and follow the instructions on an AED can provide the scientifically proven life saving care EMT-Bs do.

I would expect a professional minded patient centered care provider would know every in and out of the values and limitations of their scope of practice and its interventions, am I wrong? 



escherichiaColi0157 said:


> Gee, what IS their goal then? Wow, you have got to be kidding. Ever consider SAR EMT's? Or Wilderness EMT's or lifeguards? maybe you're thinking of your transport only basics but there are  basic's providing patient care in backcountry and extreme wilderness making limb and life decisions



These environments and the specificities of them are not related to the EMT-B curriculum or scope. 

The operational aspects and training are seperate from EMT-Bs. That is no different from firefighter/emt-bs, hazmat emt-bs, industrial medicine emt-bs, er techs with an emt-b cert and a list that goes on even outside of the austere environment. 



escherichiaColi0157 said:


> many paramedics will never be exposed to in their clean rigs. Trust me, I respect the knowledge and additional training of the medic, but not their ego trips.



So what?

I don't have figures, but if I was a betting man, I would definately wager there are more paramedics functioning in austere environments specifically for their paramedic cert (aka medical cert) than EMT-Bs specifically for their EMT cert and not another specific knowledge or skill and being an EMT is just a bonus.



funtimes said:


> I dont really disagree with this statement, however it really isnt the EMTs fault. Most people when they go to school to be an EMT, assume they are taking on a lot of responsibility, that the school will be difficult and have high standards and that their decision making ability is crucial and will be put to the test.



The issue isn't about assigning blame. It doesn't matter who is to blame, it only matters the problem is fixed.

However, we must acknowledge the problem isn't being fixed because of special interests that would lose considerably if the system was changed who constantly fight to keep things the same. 



funtimes said:


> There seems to be this notion that people who dont immediately go to Paramedic school are somehow stupid, or lazy, or just want the minimum standards, yet MOST paramedics didnt go right from EMT school to Paramedic school. Most worked as EMTs, sometimes for years, and many of them(the honest ones) will say that working as an EMT made Paramedic school less stressful and working as a brand new Paramedic less difficult..



I worked as an EMT for years and largely slept through medic school. I never suggested they were lazy, stupid, or otherwise. 

I was even forced to become an EMT, were I not forced, I would not have gone to EMT school.

But I would relate that it was a different time. We knew less than we do now and back in the day, paramedics were so rare that an EMT was likely to be the only prehospital medical provider. But the decisions that were made were operational. Every patient got one of the same handful of treatmentswe had no matter what.

It is not that EMTs were never valuable, the world evolves, but EMTs are not evolving with it and they are making themselves obsolete by not demanding their vocation advance. They do not choose this on the individual level, they choose it at the organizational level. 



funtimes said:


> The ones who say EMT experience makes no difference in Paramedic school are simply wrong. The pass rate for students with EMT experience is significantly higher than it is for those with no experience, and Ive personally seen those medics who did pass with no experience struggily mightily as brand new Paramedics, versus the ones with EMT experience who had a far smoother transition.



I am not always right. But I say with the job opportunities available to EMTs today, they may have a chance to gain experience that will be beneficial, but not only is it not guaranteed, they have a far better chance of having experience that actually harms them when in paramedic school.

I refute your assertion EMTs with experience have the highest pass rates in paramedic school. In my nearly 10 years of teaching EMS at multiple organizations, in the 2 organizations that kept records on the demographics of pass/fail, experienced EMTs were the group that failed the most. The group that not only passed but had the best grades were those with prior or concurrent university education.

In my observation, the reason experienced EMTs struggle with medic school is because 1. they think they know things they don't. 2. They have been taught incorrect information in the field. 3. As adult learners they are resistant to changing preconceived notions and most always never reconcile this. I have seen it so much that I can tell you if they are going to pass or fail usually within a couple of weeks with them. Now and again I am wrong about one of them, but not often.

Yes, new people struggle, whether it is a new nurse, new paramedic, or new doctor. However, the ones with more knowledge will often become more proficent providers faster because they gain more insight from every experience.

If you want to see for yourself, observe a new EMT with only EMT training. Compare this to observations of new EMTs with prior basic science or other healthcare education.


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## JPINFV (Oct 11, 2012)

funtimes said:


> I dont really disagree with this statement, however it really isnt the EMTs fault.


I agree that it isn't the fault of new EMTs. Those with experience that make the choice to not work toward moving EMS from a technical trade to a profession, however, do share fault. 



> The ones who say EMT experience makes no difference in Paramedic school are simply wrong. The pass rate for students with EMT experience is significantly higher than it is for those with no experience, and Ive personally seen those medics who did pass with no experience struggily mightily as brand new Paramedics, versus the ones with EMT experience who had a far smoother transition.



...which is, at it's base, because of cruddy schools and cruddy instructors who treat the cruddy minimum somehow as a maximum. Minimum experience requirements are a band aid to an arterial bleed that needs to be sutured.


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## Brandon O (Oct 11, 2012)

I was trying to figure out why I find these discussions so vexing, and I think it's this: despite everybody knowing exactly what's wrong with the world, it's still just talk. So we simply do it all again next month. We have these same back-and-forths around the crew room or the ambulance bay.


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## triemal04 (Oct 11, 2012)

Brandon Oto said:


> I was trying to figure out why I find these discussions so vexing, and I think it's this: despite everybody knowing exactly what's wrong with the world, it's still just talk. So we simply do it all again next month. We have these same back-and-forths around the crew room or the ambulance bay.


Talk is cheap.  Very, very cheap depending on the setting.  

But...the more people that are talking about it and recognizing the problem, the better the odd's are that someone will actually start to act on it and try and improve things.  The changes that were/are being adopted by NREMT (and thus some states), though quite small, are still a step in the right direction.

Of course, "better" is still a relative term were EMS is concerned.


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## Wheel (Oct 11, 2012)

This discussion has been very interesting, and as a new medic who went straight through to medic without working as a basic here are my thoughts.

First, it helped that I was in school mode still, unlike my classmates who worked previously as emts. Second, it helped that I had taken a lot of basic science as a chemistry major before starting this. These things put me way ahead of my classmates in understanding physiology, drug reactions, nerve pathways in the heart, hemodynamics, and drug math, among other things. They were better at skills, for the most part, and we helped each other. What I can say, however, is that it was much easier for them to teach me patient packaging and movement than it was for me to teach them hemodynamics or even basic algebra. They just didn't have a good time understanding these things, which are essential in my opinion.

I am in my first job as a medic now, where I'm working double medic until they release me in six months or so to run my own truck (because I have no experience.) I admit that logistical and operational issues are a huge learning curve for me right now, and working as an emt would have made that much easier. I would argue that the science behind what we do is much more important for the future of ems and much harder to teach on the job than monkey skills and ambulance operations, and this is the direction than ems needs to go.


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## Brandon O (Oct 12, 2012)

triemal04 said:


> Talk is cheap.  Very, very cheap depending on the setting.
> 
> But...the more people that are talking about it and recognizing the problem, the better the odd's are that someone will actually start to act on it and try and improve things.  The changes that were/are being adopted by NREMT (and thus some states), though quite small, are still a step in the right direction.



Well, how about this for a step in the right direction? When an EMT comes onto a forum like this asking questions and trying to learn, rather than a dozen replies telling him to get a degree and opining about the state of EMS training (quickly spiraling into Yet Another Thread Like This), we just try to answer the questions?

Can we all commit to that? Or is that not as fun? I can't tell you how many times I was on the other side of that when I was starting out, and was utterly baffled by the contradictory nature of what I was hearing. The internet has massive potential as a tool for learning. How much can someone believe in improving the educational standards if they aren't willing to contribute?


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## Veneficus (Oct 12, 2012)

triemal04 said:


> Talk is cheap.  Very, very cheap depending on the setting.
> 
> But...the more people that are talking about it and recognizing the problem, the better the odd's are that someone will actually start to act on it and try and improve things.  The changes that were/are being adopted by NREMT (and thus some states), though quite small, are still a step in the right direction.
> 
> Of course, "better" is still a relative term were EMS is concerned.



Some of us have been trying to change things for a long time.

There have been more setbacks than victories though.

I think it is going to actually take the collapse of the US healthcare system (coming soon) in order to fix it.

When that happens, the fewer of the voacational minded people around the easier it will be.

Additionally, I think telling people to get a degree and then test into EMS will increase the number of people in EMS with a degree faster than hoping the ones already in without a degree will step up.


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## VFlutter (Oct 12, 2012)

Brandon Oto said:


> Well, how about this for a step in the right direction? When an EMT comes onto a forum like this asking questions and trying to learn, rather than a dozen replies telling him to get a degree and opining about the state of EMS training (quickly spiraling into Yet Another Thread Like This), we just try to answer the questions?
> 
> Can we all commit to that? Or is that not as fun? I can't tell you how many times I was on the other side of that when I was starting out, and was utterly baffled by the contradictory nature of what I was hearing. The internet has massive potential as a tool for learning. How much can someone believe in improving the educational standards if they aren't willing to contribute?



While I agree about not letting threads spiral into the reoccurring debates I do not think blindly answering every question posted on the forum will be a step in the right direction. There are constantly questions being asked that could easily be found in a decent patho book or with some research on the Internet. Serving up over simplified explanations to complex issues will not solve the problem. Most will never truly understand a lot of the concepts that are constantly asked about without first having the foundational (Bio,chem,patho,pharm) knowledge that EMS education lacks. So instead of encouraging people to pursue higher education we should just expect them to learn from this forum and apply that knowledge in the real world? Sounds counterproductive and dangerous.


Also, it is not nearly as fun. These debates cure my boredom


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## triemal04 (Oct 12, 2012)

Brandon Oto said:


> Well, how about this for a step in the right direction? When an EMT comes onto a forum like this asking questions and trying to learn, rather than a dozen replies telling him to get a degree and opining about the state of EMS training (quickly spiraling into Yet Another Thread Like This), we just try to answer the questions?
> 
> Can we all commit to that? Or is that not as fun? I can't tell you how many times I was on the other side of that when I was starting out, and was utterly baffled by the contradictory nature of what I was hearing. The internet has massive potential as a tool for learning. How much can someone believe in improving the educational standards if they aren't willing to contribute?


I don't know, is that what happened in this thread?  I'm not going to bother reading the whole thing so I don't know.  In looking at the comment I specifically responded to, if the poster is actually here to ask questions and learn, then why are they immedietly getting defensive when a deficiency is pointed out?  Instead of trying to understand why someone said something and figure out if the statement they reacted to is right...they got upset instead.  Not very condusive to learning, and leads to the type of situation you're talking about.


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## triemal04 (Oct 12, 2012)

Veneficus said:


> Some of us have been trying to change things for a long time.
> 
> There have been more setbacks than victories though.
> 
> ...


And if nobody was even talking about it, where do you think things would be at?  If nobody even mentioned bucking the status quo what would happen?  

Whatever your view of where EMS is at and where it is/should be/could be going, changes have to start somewhere.  And getting people aware of problems and solutions is better than nothing.


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## Brandon O (Oct 12, 2012)

triemal04 said:


> I don't know, is that what happened in this thread?



Not so much here, but it is incredibly common.


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## Jambi (Oct 12, 2012)

triemal04 said:


> And if nobody was even talking about it, where do you think things would be at?  If nobody even mentioned bucking the status quo what would happen?
> 
> Whatever your view of where EMS is at and where it is/should be/could be going, changes have to start somewhere.  And getting people aware of problems and solutions is better than nothing.



Change does not occur by consensus with these sorts of things. It's not a democratic process.  Look up the Elite model  of policy creation.  That is what we, and the rest of EMS, are subjected to.  Don't let cries of national associations and unions fool you.  Once such organizations become large enough, they switch over to the elite model and policy creation, direction, etc., no longer becomes a function of the members except by way of mass-manipulation and pandering for support.


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## triemal04 (Oct 12, 2012)

Jambi said:


> Change does not occur by consensus with these sorts of things. It's not a democratic process.  Look up the Elite model  of policy creation.  That is what we, and the rest of EMS, are subjected to.  Don't let cries of national associations and unions fool you.  Once such organizations become large enough, they switch over to the elite model and policy creation, direction, etc., no longer becomes a function of the members except by way of mass-manipulation and pandering for support.


Yeah?  And?  I never said anything about a consensus.  It does not, and has not taken a majority of all EMS providers agreeing on something before change occurs.

It just takes a group that is willing to put in the effort and get's the right people to listen.

Is that the best way?  There's benefits and drawbacks, but, realistically it's what happens and how the system works.


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## Veneficus (Oct 12, 2012)

triemal04 said:


> Yeah?  And?  I never said anything about a consensus.  It does not, and has not taken a majority of all EMS providers agreeing on something before change occurs.
> 
> It just takes a group that is willing to put in the effort and get's the right people to listen.
> 
> Is that the best way?  There's benefits and drawbacks, but, realistically it's what happens and how the system works.



I think the overall issue is that because of those with financial interest in keeping things in EMS how they are have both the money and political power to block any change or even attempt, the best we can hope to do is instill the better way in the mindset of providers so that when the resources to continue business as usual are gone, the new leadership will believe in a progressive solution.


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## triemal04 (Oct 12, 2012)

Veneficus said:


> I think the overall issue is that because of those with financial interest in keeping things in EMS how they are have both the money and political power to block any change or even attempt, the best we can hope to do is instill the better way in the mindset of providers so that when the resources to continue business as usual are gone, the new leadership will believe in a progressive solution.


Maybe.  If that was to happen now or in the next couple years, I don't think so.  Ever heard "meet the new boss, same as the old boss?"  If there was a sudden (by sudden I mean over the course of say 5 years) need to change how EMS was delivered and ran, the people who would be making those decisions and influencing them are the same that are doing so now.  Would there be (depending on why change was suddenly needed) more opportunity for other, better informed and educated people to step up?  Sure.  But there really aren't that many groups or even individuals who are both moving towards the type of system I think you'd want or what I want AND are allready in a position of influence.  Even if the national gov't suddenly took an interest in reforming EMS, the initial people they'd be consulting would be the ones making decisions and policy now.  While there'd be opportunity, it wouldn't be the easy deal you make it sound like.

Gettting people better informed and maybe active in trying for change or seeking leadership goals is part of why simply talking about an issue can help.  It's just can be a slow process.  But, like I said above, all it takes is a group getting together and being able to touch the right people...then you start getting people who can influence policy.


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## MexDefender (Oct 12, 2012)

Besides the top brass who call the shots and keep things unchanged you would have to convince hundreds of thousands of EMS personnel to enact change by simply putting on a shirt saying change ems or some other big PR stunt that gets notice by national media. Another problem is an informed populace, almost everyone thinks if you work on an ambulance you must be a paramedic who saves lives and is "like a doctor". 

The youth of EMS could battle this and maybe in time it could show results but everyone in the field is too complacent to do anything big instead just harp and talk about it.


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## Jambi (Oct 12, 2012)

Change is not as easy as PR or media attention, nor does it lie on the desk of top brass as they're largely irrelevant.  

Any meaningful change is with law makers and who gives them the most money. It's all about policy, and the rank-and-file just don't merit atttention. Just look at the mostly irrelevent occupy movement. What change did they effect, none.  Currently EMS, and any change associated with it, is inexorably linked with fire, and since they're the dominant force (money, union, association, etc.), their interests are served first.

Now, since EMS is regulated at the state level multiply all that by 50 states.

There has been some headway made in california. All EMS training programs were mandated to be associated with colleges, this shut down most, if not all, fire-based programs.  furthermore, standards were increased, hours upped, perfomance standards for medic (with yearly verification) was put in place.

The state and local ems and medical directors are gradually finding their teeth.


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## hogwiley (Oct 14, 2012)

Everyone keeps talking about the lack of training for EMT Basics, but one problem Ive noticed is a general mentality in EMS, and in particular among new EMTs. Im not sure exactly how to describe it, but it basically seems to be an attitude that their job isnt really patient care. 

For an example someone on here summed it up nicely when they mentioned a Paramedic having to wipe an incontinent patients butt. It was apparently hilarious that this almighty Paramedic would be reduced to performing such a mindless and unglamourous task. Nevermind you have BSNs in ICUs with far more education and training and making a lot more money doing it all shift long. 

It really is a problem when patient care is considered embarrasing or something you are above, especially when you consider how little training EMTs have. It shows immaturity and a lack of professionalism. This seems to be less a problem with really experienced Paramedics, but a lot more with younger EMTs and medics. I was told by an ED nurse whose ED employs CNAs instead of EMTs as techs that THIS was the biggest reason.

I dont know if its the influence of Fire on EMS, where its all about lights and sirens and wearing a uniform with neat patches, instead of being about taking care of patients, but its been a glaring difference Ive noticed between EMS and other health care professionals.


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## Aidey (Oct 14, 2012)

There is a very simple explanation for that. CNAs are taught personal hygeine care. EMTs are not. It isn't even mentioned. The embarrassment isn't just from immaturity and lack of professionalism, it is from being put in an position that they aren't trained for, and needs to be handled a certain way. 

The reason you see experienced paramedics jumping in to help is very likely because they have observed enough over the years to make up for the lack of training in caring for a pts personal hygiene. I've had nurses show me what to do, and now I'm pretty comfortable with it. I didn't like cleaning pts before, not because I thought it was below me, but because I was worried about causing the patient discomfort because I was doing something incorrectly.


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## RocketMedic (Oct 14, 2012)

My first part-time agency had our on-duty hours as para-CNAs. I didn't mind (still don't), but it was uncomfortable to be put in a position where I was first-out 911 and still immediately responsible for inpatient care (ie bathing). With no CNA training and crappy RN support, it wasn't optimal, and I quit for that reason among others.

That being said, I agree that many new EMTs seem to be "above" patient care. I'll stay on scene if patient presentation permits to change a diaper or make them comfortable. There's not much more humiliating than wearing your own poop to go see other people.


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## Handsome Robb (Oct 14, 2012)

hogwiley said:


> It really is a problem when patient care is considered embarrasing or something you are above, especially when you consider how little training EMTs have. It shows immaturity and a lack of professionalism. This seems to be less a problem with really experienced Paramedics, but a lot more with younger EMTs and medics. I was told by an ED nurse whose ED employs CNAs instead of EMTs as techs that THIS was the biggest reason.
> .



Since all young EMTs and Medics are immature pricks, right?


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## NomadicMedic (Oct 14, 2012)

NVRob said:


> Since all young EMTs and Medics are immature pricks, right?



Only you buttwiper.


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## JPINFV (Oct 14, 2012)

NVRob said:


> Since all young EMTs and Medics are immature pricks, right?



Enough to argue, at a minimum, that it's a justified stereotype. How many 19, 20 year old EMTs would stick around to help roll a dialysis patient who had a BM during the transport?


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## VFlutter (Oct 14, 2012)

*Mini Rant*



NVRob said:


> Since all young EMTs and Medics are immature pricks, right?



Not all have that mentality but a few do and unfortunately those are the ones you usually remember. 

It is not a problem specific to EMS but medical professions as a whole. A lot of new people have tunnel vision for only the most exciting and glorious parts of the job. It takes experience to realize the importance of the little things. 

How many times have you seen the mentality of "Why would I clean up my patient who just :censored::censored::censored::censored: themselves? That is the nurse's job. They can take care of it when they get to the hospital" What those people fail to see is that the "awesome" septic shock patient in the ICU vented and on pressors might have all started from an ulcer from laying in stool/urine. If you think it is above you to clean up a patient then you have no right to touch that patient in the ICU. That is why I do not take offense when people refer to nurses as "***-wipers", I just shrug it off as ignorance. 

If you get into the medical field you have to realize that some-days you may have to be elbow deep in C. Diff. :censored::censored::censored::censored: happens


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## hogwiley (Oct 15, 2012)

> Since all young EMTs and Medics are immature pricks, right?



I never said all, but were not exactly talking about a tiny percentage either.


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## rescue1 (Oct 15, 2012)

On the subject of cleaning a patient if they made a whoopsie during transport, I can't see it being safe or effective for you to unrestrain the patient, roll the patient to the side and clean (all by yourself), and then re-restrain them. Wouldn't it make more sense to move them to the hospital bed first where there is little chance of being involved in an auto accident and so you have some extra hands?


I'm not advocating not cleaning our patients, and I'd certainly stick around the hospital if they needed help with cleaning a BM, but I feel like it is still a task best accomplished in a hospital rather then a moving ambulance.


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## Zman6 (Nov 20, 2012)

*UCLA Expanded Scope Class Online*

Has anyone taken the free LACo Expanded scope class online through UCLA?


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