# Why aren't all EMTs are least trained with ALS?



## DragonClaw (Mar 14, 2019)

In my studies,  for A-Z, call additional support/ALS. 

The more I see it, the more I wonder why everyone doesn't get that training.  Yeah,  more time consuming and more stuff to learn, but it seems to be used regularly.


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## NPO (Mar 14, 2019)

DragonClaw said:


> In my studies, for A-Z, call additional support/ALS.
> 
> The more I see it, the more I wonder why everyone doesn't get that training. Yeah, more time consuming and more stuff to learn, but it seems to be used regularly.


Are you adding why aren't all EMTs Paramedics? 

Because we don't need everyone to be a paramedic. There is huge cost with having paramedics. Not just in training, but maintenance of skills, certs, insurance, medical direction, equipment, etc...


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## DrParasite (Mar 14, 2019)

economics.  ALS is more expensive than BLS, paramedic school is much longer than EMT school
studies have shown that all ALS systems results in medics who are not as proficient at critical skills, because they spend much of their time on non-ALS patients.
not every area can support an all ALS system, due to call volume, at least not without an infusion of tax money.
your studies are correct: NREMT says call for additional help.  The longer you do the job, the more you will realize that many of your patients don't need ALS, or won't benefit from ALS


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## DragonClaw (Mar 14, 2019)

DrParasite said:


> your studies are correct: NREMT says call for additional help.  The longer you do the job, the more you will realize that many of your patients don't need ALS, or won't benefit from ALS



Huh.  Probaby my inexperience, but the amount of scenarios that requires ALS is staggering.  But, perhaps it's the frequency of occurrence rather than the multitude of _possible _ situations that require ALS .


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## DrParasite (Mar 14, 2019)

There are several types of calls that will experience in your career: those that should receive ALS, those that ALS would be nice to have and medications or interventions would be beneficial, and those where ALS is needed and if not received, the patient WILL die.  And then there are those calls where ALS is not needed, the patient just needs a ride to the ER (bonus points if they are horizontal, but many could just as easily go by cab).

Experience of providers, medical director's guidelines, even geography of coverage area can affect if a provider thinks the patient should be an ALS or BLS treat.

If you want to see the various differences we went 11 pages & 219 posts on this topic: https://emtlife.com/threads/is-a-broken-arm-an-als-or-bls-call.14922/

The few studies that I have seen show that ALS treat & transport does not affect mortality of EMS patients, at least not when compared to BLS treat and transport. ALS can make the patient feel better, have an overall improvement in comfort and quality of life (and yes, at times, they can saves lives). 

However there are also a ton of EMS calls that we get that a paramedic can't do more for, or might just start an IV lock and give the stare of life as the patient gets a nice ride to the ER.  Take that IV lock out, and and EMT can give the stare just as well as a paramedic.

I'm not saying paramedics aren't needed, or have no place in EMS systems, but there are many areas & states that still utilize BLS ambulances with an ALS chase car, and I don't see dead bodies piling up on the streets because they don't always have paramedics on every ambulance call.  

When I looked at the stats at my first EMT agency in the late 90s, out of 5,000 annual calls, maybe 20% were treated by ALS providers coming in a flycar.


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## StCEMT (Mar 14, 2019)

Here are some small scale numbers for you. Between Sunday and 0400 this morning I ran 37 calls. I can think of 3 that absolutely needed to go to the hospital. Only 1 needed an ALS assessment as a rule out. None needed any true ALS intervention beyond 12 lead/IV.


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## mgr22 (Mar 14, 2019)

StCEMT said:


> Here are some small scale numbers for you. Between Sunday and 0400 this morning I ran 37 calls. I can think of 3 that absolutely needed to go to the hospital. Only 1 needed an ALS assessment as a rule out. None needed any true ALS intervention beyond 12 lead/IV.



So maybe -- and I'm just saying, maybe -- based on what you, DrParasite and others have said, a more realistic model for EMS would be a single level of certification somewhere between medic and EMT with, say, 600-800 hours of instruction. We'd get rid of rarely used and non-essential procedures in paramedic protocols, lower scope of practice but perhaps raise quality of care within that redefined scope, and abandon force-fits like community paramedicine (best left to clinicians with more training in chronic conditions and well care). We'd also end all those arguments about degree requirements (no) and whether EMS is a profession or a trade (the latter). The effect on outcomes would be negligible, since most calls don't require ALS, and cost of prehospital care would drop.

Or not.


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## DesertMedic66 (Mar 14, 2019)

mgr22 said:


> So maybe -- and I'm just saying, maybe -- based on what you, DrParasite and others have said, a more realistic model for EMS would be a single level of certification somewhere between medic and EMT with, say, 600-800 hours of instruction. We'd get rid of rarely used and non-essential procedures in paramedic protocols, lower scope of practice but perhaps raise quality of care within that redefined scope, and abandon force-fits like community paramedicine (best left to clinicians with more training in chronic conditions and well care). We'd also end all those arguments about degree requirements (no) and whether EMS is a profession or a trade (the latter). The effect on outcomes would be negligible, since most calls don't require ALS, and cost of prehospital care would drop.
> 
> Or not.


I don’t think limiting prehospital services is anywhere near the right answer. There are situations where having a medic on scene is the best thing for the patient. 

If there are no medics lost skills may include: blood products, intubation, surgical crics, RSI, needle decompression, chest tubes, sedation, pain management, 12-lead interpretation, conscious IO, etc. The answer is not to give these advanced skills that can in fact be live saving to a provider with lesser training.


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## mgr22 (Mar 14, 2019)

DesertMedic66 said:


> I don’t think limiting prehospital services is anywhere near the right answer. There are situations where having a medic on scene is the best thing for the patient.
> 
> If there are no medics lost skills may include: blood products, intubation, surgical crics, RSI, needle decompression, chest tubes, sedation, pain management, 12-lead interpretation, conscious IO, etc. The answer is not to give these advanced skills that can in fact be live saving to a provider with lesser training.



Of the skills you mentioned, I'm thinking blood products, surgical crics, RSI, and chest tubes probably wouldn't make the cut for 600-800-hour medic/EMTs. And I agree there are situations where a medic on scene is the best thing for a patient. I also think there are lots of situations where a doctor on scene would be the best thing for a patient. That's almost never an option in the U.S., but we've adapted.


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## StCEMT (Mar 14, 2019)

I'd disagree with lowering it as well. Just because that was what this week was like, I have also gone to the resus bay multiple times in a row with critical patients, transported GSW's multiple days in a row, been dispatched to a couple arrests in a day, etc. Those are all patients that required intubation, pressors, multiple meds for obstructive airway issues, decompressions, crics, and other things that make up the small percentage of patients where our knowledge and toolbox actually make a difference in outcomes.

I do think a mid level training as baseline is something worth thinking about being the standard, especially in areas with longer response times.


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## mgr22 (Mar 14, 2019)

StCEMT said:


> I'd disagree with lowering it as well. Just because that was what this week was like, I have also gone to the resus bay multiple times in a row with critical patients, transported GSW's multiple days in a row, been dispatched to a couple arrests in a day, etc. Those are all patients that required intubation, pressors, multiple meds for obstructive airway issues, decompressions, crics, and other things that make up the small percentage of patients where our knowledge and toolbox actually make a difference in outcomes.
> 
> I do think a mid level training as baseline is something worth thinking about being the standard, especially in areas with longer response times.



You and DesertMedic have a point if you're talking about saving someone who would have forfeited life or quality of life without high-end paramedic intervention prehospitally -- i.e., prompt therapy that wouldn't be part of a 600-800-hour curriculum. I'm not sure how often that happens. I don't think I had more than a handful of cases like that in 20 years.

I don't doubt your patients needed what you did for them. I'm just wondering how many of them could have been stabilized to a lesser extent, treated definitively at a hospital, then discharged intact.


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## StCEMT (Mar 14, 2019)

There is the other end of the spectrum too. If you have a smaller foundation of knowledge, the way which you approach a true resus situation will be different. There is a lot to be said about knowing when to not to do something or to do it in a much more conservative manner. To do so requires understanding more of the how and why which is going to get cut out with shorter schools and lower standards.

If there was a consistently high standard, we wouldn't be fighting things like backboard at the slightest back pain, 15L NRB for a slightly low O2 sat, or flooding trauma patients with liters of saline. Yet it's still done.

I absolutely believe BLS has it's place with most of what we do and ALS is over emphasized. Where I work, it's only just now getting approved that a BLS provider can even tech a 911 call. Just don't cut the standards for ALS, restructure how we operate if anything so each one is being allocated appropriately.


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## mgr22 (Mar 14, 2019)

StCEMT said:


> There is the other end of the spectrum too. If you have a smaller foundation of knowledge, the way which you approach a true resus situation will be different. There is a lot to be said about knowing when to not to do something or to do it in a much more conservative manner. To do so requires understanding more of the how and why which is going to get cut out with shorter schools and lower standards.
> 
> If there was a consistently high standard, we wouldn't be fighting things like backboard at the slightest back pain, 15L NRB for a slightly low O2 sat, or flooding trauma patients with liters of saline. Yet it's still done.
> 
> I absolutely believe BLS has it's place with most of what we do and ALS is over emphasized. Where I work, it's only just now getting approved that a BLS provider can even tech a 911 call. Just don't cut the standards for ALS, restructure how we operate if anything so each one is being allocated appropriately.



All good points.


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## Akulahawk (Mar 15, 2019)

The basic EMT is perfectly suited for less critical calls and, under certain circumstances, are better at it because they think about _transport_ as an immediate intervention. Too often we get stuck on the "stay and play" side of things when "load and go" is what must be done. I'm OK with the basic EMT being the tech on certain calls, as long as I'm reasonably quickly available as an ALS resource because I want them to be a little uncomfortable and I want them to learn how to do very good patient assessments. I want them to learn when to call ALS, when it's appropriate for them to "keep" the patient and when it's appropriate for them to PUHA to the ED because they can get the patient to the ED faster than they can get ALS to the patient. 

Now then, when it comes to 911 stuff, I would prefer to have either another Paramedic or an AEMT as a partner because then I have another set of ALS-capable hands for those few times that I would need them. If that's not a possibility, I will absolutely train or want my EMT partner trained to assist me in nearly anything I need done. There's actually very little that's not a monkey skill when it comes to setting up for things... all the "work" is done on my end by determining that a particular thing needs to be done... or not. The AEMT is going to be easier to work with on this end but an EMT is certainly capable of grabbing things and setting up various pieces of equipment. 

Why isn't this done more frequently? I suspect it's mostly economics. With the EMT vs AEMT, the EMT is always going to be cheaper. Dual Medic is going to be among the more expensive ways to staff an ambulance. It's also likely done this way because it's often cheaper on the student to go from EMT straight to Paramedic than it is to go EMT to AEMT to Paramedic. Now if you bump the EMT education up to the 600-800 hour range, you might as well get them to the current AEMT level. That means also bumping the AEMT up to the current Paramedic level and the Paramedic should therefore (and be much less common than now) be bumped up to a point where about 80% or so of all CCT stuff can be done by them instead of a dedicated CCT-RN. That also means that the CCT-RN and CFRN gets bumped up significantly as well... so they handle only the most weird and difficult of cases because the Paramedics handle the rest... None of that will be cheap and will only likely make a difference in a very few number of cases. However if you make it your goal, the lower levels get far better at what they do and that's where the patients will see improvements in care.


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## Aprz (Mar 19, 2019)

In EMT school and your book, almost every scenario is an emergency like strokes, heart attacks, cardiac arrest, etc. When I got out of EMT school, I thought every call was going to be what I thought was 9-1-1 worthy in my mind (you better be dying or else!). In real life, the majority of calls are tummy pain, cold/flu-like symptoms, generalize weakness, mechanical falls, etc. Many of those calls do not require a paramedic. In my system, we are all ALS, but we very infrequently use our ALS skills. I rarely even give oxygen...


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## DrParasite (Mar 19, 2019)

Akulahawk said:


> With the EMT vs AEMT, the EMT is always going to be cheaper.


Not always; we have several AEMTs in our system, and they don't get paid anymore than EMTs.  But they have a more difficult credentialing process (all of our trucks have a paramedic on them).

my other system only recognized EMTs and paramedics.  We had several people who were AEMTs on the ambulance, as well as a few firefighters on the municipal departments.  The medical director only permitted them to function as EMTs.  Well, on paper anyway....



Aprz said:


> In real life, the majority of calls are tummy pain, cold/flu-like symptoms, generalize weakness, mechanical falls, etc. Many of those calls do not require a paramedic.


And that's the truth.  EMS educators try to prepare students for the worse case scenario, when the reality is, most patients simply need a ride to a hospital.  some could be treated as well at a local urgent care or PMD.  

That doesn't mean that you can't get dispatched to a minor call and the patient need aggressive medical attention or else they are going to die, or you won't have to handle a sick EMS call, but to say that EVERY patient needs ALS or they are going to die is intentionally lying to people at best, fear mongering at worst.

Go on a ride along or two, and see how many patients require ALS interventions, compared to those who just need a ride to the hospital.  you will notice a differences.


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## DragonClaw (Mar 19, 2019)

DrParasite said:


> Go on a ride along or two, and see how many patients require ALS interventions, compared to those who just need a ride to the hospital.  you will notice a differences.



I have done so.  We had some respiratory distress,  a patient transfer,  a lady with sores on her head. MVC involving a semi and two passenger vehicles. MVC with two passenger vehicles. 



Aprz said:


> In EMT school and your book, almost every scenario is an emergency like strokes, heart attacks, cardiac arrest, etc.



So true.  Leaning about some pharmacology, all about contradictions and indicators. It feels like everyone's dying. But ... Better make sure they feel a burning with the nitro for potency. 

JVD and all of that, how decompensated shock is kind of the end.


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## DrParasite (Mar 19, 2019)

DragonClaw said:


> I have done so.  We had some respiratory distress,  a patient transfer,  a lady with sores on her head. MVC involving a semi and two passenger vehicles. MVC with two passenger vehicles.


Great, and now how may of those patients required a paramedic intervention?

In my former system, the only ones that would even dispatch ALS would be the resp distress and maybe the crash involving the semi (unless there was more to it, it might just be a BLS ambulance).


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## DragonClaw (Mar 19, 2019)

DrParasite said:


> Great, and now how may of those patients required a paramedic intervention?
> 
> In my former system, the only ones that would even dispatch ALS would be the resp distress and maybe the crash involving the semi (unless there was more to it, it might just be a BLS ambulance).



As far as I remember,  we keep a medic on all trucks.  But nothing really happened. Mostly just transport with  various urgencies.


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## DrParasite (Mar 20, 2019)

You misunderstood my question.  Many ALS systems operates with 1 EMT and 1 paramedic on the truck.  If the patient requires no ALS interventions, the paramedic drives, and the EMT is in the back with the patient.  If they require ALS, the EMT drives.  if it's borderline, usually the EMT drives and the paramedic does the stare of life.

So in your ride alongs, with minimal interventions performed, do you think having a paramedic there helped the patient?  or could the patient have been treated appropriately with just an EMT crew?


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## Trvlr (Mar 20, 2019)

DrParasite said:


> You misunderstood my question.  Many ALS systems operates with 1 EMT and 1 paramedic on the truck.  If the patient requires no ALS interventions, the paramedic drives, and the EMT is in the back with the patient.  If they require ALS, the EMT drives.  if it's borderline, usually the EMT drives and the paramedic does the stare of life.



Fire/EMS here, that's how we do it in our system. However our department is pushing to get a lot of the EMT-B's to AEMT for the reasons mentioned above about assisting in ALS procedures, drugs, etcs.  

I'd also say a majority of the calls that end up "ALS" are more so for pain management and comfort measures that aren't necessary to save life or limb.


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## DragonClaw (Mar 20, 2019)

DrParasite said:


> You misunderstood my question.  Many ALS systems operates with 1 EMT and 1 paramedic on the truck.  If the patient requires no ALS interventions, the paramedic drives, and the EMT is in the back with the patient.  If they require ALS, the EMT drives.  if it's borderline, usually the EMT drives and the paramedic does the stare of life.
> 
> So in your ride alongs, with minimal interventions performed, do you think having a paramedic there helped the patient?  or could the patient have been treated appropriately with just an EMT crew?


I see your point.  It's a good one.

Where's a shirt,  I need to eat it.

What's the "Stare of life" because most states I know are Death Stares.


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## DrParasite (Mar 21, 2019)

DragonClaw said:


> What's the "Stare of life" because most states I know are Death Stares.


The stare of life wasn't covered in your EMT class?  epic fail......

the stare of life is simply monitoring your patient.  You can also have the IV lock of life, where all a paramedic does is set up an IV lock in the patient's arm, and then monitor the patient on the way to the hospital.  The sarcasm involved questions how much does simply having that IV access affect the patient's condition?

Basically, when you aren't doing any interventions for a patient (no meds, no breathing treatment, no electricity,  no chest decompression, no intubation, you get the idea), but transporting them to the hospital for definitive care by an MD.


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## DesertMedic66 (Mar 21, 2019)

DrParasite said:


> You misunderstood my question.  Many ALS systems operates with 1 EMT and 1 paramedic on the truck.  If the patient requires no ALS interventions, the paramedic drives, and the EMT is in the back with the patient.  If they require ALS, the EMT drives.  if it's borderline, usually the EMT drives and the paramedic does the stare of life.
> 
> So in your ride alongs, with minimal interventions performed, do you think having a paramedic there helped the patient?  or could the patient have been treated appropriately with just an EMT crew?


The stare of life. I’m gonna have to use that one.


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## rescue1 (Apr 4, 2019)

Since I finally get to look at this stuff from the other side in the ED, I can share some of my experiences. I remember how stressed people (myself included) would get over whether or not certain patients were ALS or BLS patients. Was their pressure too high for an EMT to ride it in? This patient is concerning for a cervical fracture--is that ALS? People would get in trouble for 'inappropriately' BLSing syncope. People would wait on scene with stroke patients so ALS could ride it in.

Rest easy, because 90% (or more, probably) of the time it makes absolutely no difference. Hypertension? Doesn't matter. Stroke, assuming no airway compromise? ALS saves nurses the 30 seconds it takes to put in a line. I remember medics rushing in a patient who they described as a "really interesting case" who was discharged two hours later. Meanwhile, private BLS units who may or may not have actually taken vitals would drop off floridly septic geriatrics from the nursing homes who would end up in the ICU. 

There are certainly patients that benefit from ALS--certain respiratory emergencies, early recognition of STEMI, status epilepticus, hypoglycemia--but there are a large majority of patients who aren't going to need or benefit from ALS procedures. There's also a lot of controversy on whether certain procedures are beneficial in the long run (prehospital intubation has been the big one for the last decade or more, ALS trauma care is another).

All of that being said, the most important thing a paramedic brings to the table vs an EMT is education, understanding of pathophysiology, and experience, so I strongly disagree with the idea that we should lower EMS education any more than it already is.


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## wtferick (Apr 6, 2019)

rescue1 said:


> Since I finally get to look at this stuff from the other side in the ED, I can share some of my experiences. I remember how stressed people (myself included) would get over whether or not certain patients were ALS or BLS patients. Was their pressure too high for an EMT to ride it in? This patient is concerning for a cervical fracture--is that ALS? People would get in trouble for 'inappropriately' BLSing syncope. People would wait on scene with stroke patients so ALS could ride it in.
> 
> Rest easy, because 90% (or more, probably) of the time it makes absolutely no difference. Hypertension? Doesn't matter. Stroke, assuming no airway compromise? ALS saves nurses the 30 seconds it takes to put in a line. I remember medics rushing in a patient who they described as a "really interesting case" who was discharged two hours later. Meanwhile, private BLS units who may or may not have actually taken vitals would drop off floridly septic geriatrics from the nursing homes who would end up in the ICU.
> 
> ...


Tell me about it lol
Our directors are having meetings with EMS. Tired of getting all these stroke patients sent BLS to us. With the EMTs telling us "language barrier."


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## johnrsemt (Apr 8, 2019)

What can a medic do for a stroke patient that a basic can't do?  
  Put them on a monitor and do a 12 lead:  won't make much difference:  I have seen stroke patients sent to CT before that was done.
   IV:  saves the ED a couple of minutes.
  When I was a basic and on a BLS truck we would transport emergent to the closest appropriate hospitals and not wait on scene for the medics.  9/10 times the medics would be disregarded cause they wouldn't be able to catch us:  CVA's, Possible MI's, Resp Distress and Failure, Severe allergic reactions.  Load and go.


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## DesertMedic66 (Apr 8, 2019)

johnrsemt said:


> What can a medic do for a stroke patient that a basic can't do?
> Put them on a monitor and do a 12 lead:  won't make much difference:  I have seen stroke patients sent to CT before that was done.
> IV:  saves the ED a couple of minutes.
> When I was a basic and on a BLS truck we would transport emergent to the closest appropriate hospitals and not wait on scene for the medics.  9/10 times the medics would be disregarded cause they wouldn't be able to catch us:  CVA's, Possible MI's, Resp Distress and Failure, Severe allergic reactions.  Load and go.


Depending on your area: Assess the patients BGL to make sure it’s not just a glucose issue and advanced airway management should the patients condition deteriorate.


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## wtferick (Apr 8, 2019)

johnrsemt said:


> What can a medic do for a stroke patient that a basic can't do?
> Put them on a monitor and do a 12 lead:  won't make much difference:  I have seen stroke patients sent to CT before that was done.
> IV:  saves the ED a couple of minutes.
> When I was a basic and on a BLS truck we would transport emergent to the closest appropriate hospitals and not wait on scene for the medics.  9/10 times the medics would be disregarded cause they wouldn't be able to catch us:  CVA's, Possible MI's, Resp Distress and Failure, Severe allergic reactions.  Load and go.


Most stroke related patients require at least 2 I.Vs in case they are administered TPA. The medic best have started at least one solid line...


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## DrParasite (Apr 8, 2019)

DesertMedic66 said:


> Depending on your area: Assess the patients BGL to make sure it’s not just a glucose issue


in many places, checking a BGL is an EMT skill.... and a really easy one too..... I really wish more states allowed EMTs to do it.... 





DesertMedic66 said:


> and advanced airway management should the patients condition deteriorate.


Sure.... but how often does that really happen?  I will agree that an advanced airway is needed if the patient's condition does deteriorate.  could that be managed as effectively by an OPA and BVM if ALS was not on scene?


wtferick said:


> Most stroke related patients require at least 2 I.Vs in case they are administered TPA. The medic best have started at least one solid line...


Why?  can't the ER start a line or two?  does the delay in transport benefit the patient?  And are those stroke patient's getting tPA, or is an interventional neurologist going to pull the clot out once the CT shows where it is?  or is the patient going to the neuro ICU if they are beyond the window?


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## wtferick (Apr 8, 2019)

DrParasite said:


> in many places, checking a BGL is an EMT skill.... and a really easy one too..... I really wish more states allowed EMTs to do it.... Sure.... but how often does that really happen?  I will agree that an advanced airway is needed if the patient's condition does deteriorate.  could that be managed as effectively by an OPA and BVM if ALS was not on scene?
> Why?  can't the ER start a line or two?  does the delay in transport benefit the patient?  And are those stroke patient's getting tPA, or is an interventional neurologist going to pull the clot out once the CT shows where it is?  or is the patient going to the neuro ICU if they are beyond the window?


How would a delay in transportation occur? If the Medic could not establish a line, this patient practically arived BLS.


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## DesertMedic66 (Apr 8, 2019)

DrParasite said:


> in many places, checking a BGL is an EMT skill.... and a really easy one too..... I really wish more states allowed EMTs to do it.... Sure.... but how often does that really happen?  I will agree that an advanced airway is needed if the patient's condition does deteriorate.  could that be managed as effectively by an OPA and BVM if ALS was not on scene?


That’s why I said “depending on your area”. If the patient is also not able to swallow and/or maintain their airway that EMT has no way of correcting the BGL since oral glucose is contraindicated. 

My base had a scene call for a stroke patient a couple of days ago. During the 50 minute flight to the closest stroke center the patient ended up becoming unresponsive with multiple episodes of vomiting. A BVM + OPA isn’t going to protect this patients airway mixed with the fact that EMTs are not able to deep suction (in my area). That would have resulted in a dead patient very quickly and very easily.


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## Tigger (Apr 11, 2019)

DesertMedic66 said:


> That’s why I said “depending on your area”. If the patient is also not able to swallow and/or maintain their airway that EMT has no way of correcting the BGL since oral glucose is contraindicated.
> 
> My base had a scene call for a stroke patient a couple of days ago. During the 50 minute flight to the closest stroke center the patient ended up becoming unresponsive with multiple episodes of vomiting. A BVM + OPA isn’t going to protect this patients airway mixed with the fact that EMTs are not able to deep suction (in my area). That would have resulted in a dead patient very quickly and very easily.


I think we often forget that CVAs are not always just hemiplegic and sometimes it takes more than a quick ride in to properly manage these patients. We will also bring CVAs to our local primary stroke center, get a CT, assist the facility with starting tPA if appropriate, and then monitor the infusion while starting (if needed) antihypertensives enroute to the comprehensive center. We are not CCT, but we do educate our people extensively to provide this service. I do not think such an integrated system would be possible with just BLS ambulances, and there certainly aren't enough nurses to assist in this in the area.

I spent some time in New Zealand and was quite envious of their EMS system. Paramedics have 3 year bachelor degrees and have ~70% of the US scope to include "essential ACLS drugs," cardioversion, pacing, symptom management meds, 12-lead EKG, and the other litany. No intubation, pressors, or blockers but they could call for an intensive care paramedic for that plus RSI and the other cool stuff. NZ Paramedics can handle 90% of their patients without assistance and have the education to so. They take many of the high risk/low frequency meds and procedures and give that to an elite group. This is the kind of tiered system I long for. 

Yes, in many cases all paramedics are doing is making people feel better. Even pretty sick people could probably survive a taxi ride with some vitals and oxygen, but maybe we could do better than that?


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## rescue1 (Apr 12, 2019)

Tigger said:


> I think we often forget that CVAs are not always just hemiplegic and sometimes it takes more than a quick ride in to properly manage these patients. We will also bring CVAs to our local primary stroke center, get a CT, assist the facility with starting tPA if appropriate, and then monitor the infusion while starting (if needed) antihypertensives enroute to the comprehensive center. We are not CCT, but we do educate our people extensively to provide this service. I do not think such an integrated system would be possible with just BLS ambulances, and there certainly aren't enough nurses to assist in this in the area.




I think you're speaking to a very rural coverage area, which has a very different need in regards to ALS--especially when many of your patients are going to be transferred to larger regional care centers by you, or may have 30-60 minute initial transport times. 

If you have a ten minute transport and the patient is not in respiratory compromise, the ability to start an IV and get a twelve lead are not going to impact patient outcomes, since these are simple procedures that may even be repeated anyway in the ED. While stroke patients may have a deterioration of their airway, a BLS provider should be able to manage an airway with suction/BVM for 5-10 minutes, and many ALS services may not have RSI capabilities anyway (and prehospital RSI itself can be hotly debated). Also, the vast majority of stroke patients will not deteriorate that significantly in a ten minute transport.

BGL should 100% be a BLS skill, but in areas where it is not it's probably the best indication for ALS in an area with relatively quick transport times. Yes, the hospital is going to recheck it anyway, but hypoglycemia that can be treated on scene can save the system (and patient) a lot of time and money. 

Now, all of this being said, I'm not advocating for a mass purging of paramedics in favor of a bunch of undertrained EMT-Bs in every large city, but I am saying that sometimes we take the ALS/BLS split a bit too seriously when for the vast majority of patients it likely does not impact their clinical outcome.


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## SentinelGary (Apr 14, 2019)

For the mention of rural services with extended travel times...

I for one can say that although many services (especially urban and suburban areas) may not necessarily need ALS, it is a crucial part of rural services. Like many in Kansas, our county spans wide enough where there are times it can take upwards of 45 minutes to get on scene. Without ALS intervention, there are several calls that I have been on that would have undoubtedly went sideways. Pnuemo’s than need intubation cannot wait 45 minutes for intervention, MI’s that are refractory need epi/ami, violent patients need benzo. There is such an extreme need for ALS in rural areas, but many boards don’t recognize this because most of their members are from urban areas. Without these ALS providers, our save count would surely plummet in rural services.

My director preaches on this to our A’s all the time. He is the only rural member of our board, and the one of the only reasons we still have the benefit of having A’s in Kansas. You can argue the need for ALS all day, but in the end, services like mine still require all aspects of ALS to give the care our patients deserve.


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## DrParasite (Apr 15, 2019)

SentinelGary said:


> Pnuemo’s than need intubation cannot wait 45 minutes for intervention, MI’s that are refractory need epi/ami, violent patients need benzo. There is such an extreme need for ALS in rural areas, but many boards don’t recognize this because most of their members are from urban areas. Without these ALS providers, our save count would surely plummet in rural services.


Don't Pnumos need a chest tube?  maybe a needle decompression to start, but their end goal is a chest tube right?   I don't think intubation would be my first go to intervention.... or even in the top 3.... how many pnuemos have you see that got tubed?

Don't most MIs need a cath lab?  maybe if they code they get epi, but the current studies show that survival rates are increased though early CPR/compressions and defib, not epi... although ami is def indicated if they are in a bad rhythm, to stabilize them until you get to the cath lab.

While benzos are great for violent patients, what was done before?  you restrain the patient (or even better, let LEO restrain them), and restrain them to the cot, and take them in kicking and screaming.  Been there, done that.  Yeah, chemical restraints are generally better than physical ones, but  both do work.

Please don't misunderstand, paramedics are great for a small subset of patient's (think bad asthmatics, CHFs, chest pain in identifying a STEMI and activating the CATH lab), they can initiate many life saving interventions (needle decompression, intubate airway burns, RSI if you need it), and they can give meds to make a patient more comfortable (zofran, pain meds, etc), and I am not advocating for getting rid of them, esp in the rural areas, but statistically, how much impact do the have on the mortality of the all the patients seen by rural EMS?


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## SentinelGary (Apr 15, 2019)

For lack of statistics off the top of my head, I am just making an educated guess. All I’m saying is that we have extensive use of ALS in areas like mine where all we have is sub-par level V’s in the area. I don’t know all that much about interventions, but I know there have been patients where our BLS crew had no idea what to do, and when ALS was called they were able to intervene. One example is the use of D50, I suppose. The real difference is education.

My viewpoint is against being just the wee-woo wagon. We have our equipment and staff, but when it boils down to it, we don’t have a hospital on wheels. Many of the skills that patients need, including just a higher knowledge of pathophysiology, we can’t give to BLS crews. Services out here are lucky as it is to have more than 20 EMT’s, much less an A or medic. Most if not all EMT’S are trained at a local service with an Ed program, and they don’t have time for advanced A&P education. They get basics, and maybe a little ways further.


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## Tigger (Apr 15, 2019)

DrParasite said:


> Please don't misunderstand, paramedics are great for a small subset of patient's (think bad asthmatics, CHFs, chest pain in identifying a STEMI and activating the CATH lab), they can initiate many life saving interventions (needle decompression, intubate airway burns, RSI if you need it), and they can give meds to make a patient more comfortable (zofran, pain meds, etc), and I am not advocating for getting rid of them, esp in the rural areas, but statistically, how much impact do the have on the mortality of the all the patients seen by rural EMS?


Measuring outcomes only off mortality benefits has and will always do EMS a huge disservice. There is more to healthcare than life, death, and "save counts."


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## DragonClaw (Apr 15, 2019)

Tigger said:


> Measuring outcomes only off mortality benefits has and will always do EMS a huge disservice. There is more to healthcare than life, death, and "save counts."


 But if he dies,  like really dies,  you can't measure any of the others.  I don't know how many people would be affected by having any EMT B knowing ALS, but it would be interesting to get large sample data to analyze


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## johnrsemt (Apr 15, 2019)

I like the idea of rural areas with 45 minute response time:  ours is 45 minutes to get a helicopter to us.  We have up to 2 hours response time, then 2 hours back to the base area, then 90 minutes to 2 hours to hospital by ground if we are lucky (a couple of weeks ago from base area it took 4.5 hours due to heavy snow).
I had to ground transport an Acute MI Friday due to not being able to get a helicopter in the air due to bad winds at all of their bases.  Then the ED doctor argued with us about it being a true MI (over the phone and in person) but when the cardiologist saw the 12 leads, the patient went straight to the cath lab.  ED doc didn't show the cardiologist the 12 leads until we arrived.


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## DragonClaw (Apr 15, 2019)

johnrsemt said:


> I like the idea of rural areas with 45 minute response time:  ours is 45 minutes to get a helicopter to us.  We have up to 2 hours response time, then 2 hours back to the base area, then 90 minutes to 2 hours to hospital by ground if we are lucky (a couple of weeks ago from base area it took 4.5 hours due to heavy snow).
> I had to ground transport an Acute MI Friday due to not being able to get a helicopter in the air due to bad winds at all of their bases.  Then the ED doctor argued with us about it being a true MI (over the phone and in person) but when the cardiologist saw the 12 leads, the patient went straight to the cath lab.  ED doc didn't show the cardiologist the 12 leads until we arrived.


Is that some sort of malpractice if he was harmed by the delay?


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## Tigger (Apr 15, 2019)

DragonClaw said:


> But if he dies,  like really dies,  you can't measure any of the others.  I don't know how many people would be affected by having any EMT B knowing ALS, but it would be interesting to get large sample data to analyze


Indeed this research has been done at times. However the general end goal is show mortality benefit, of which for many patients who receive paramedic care there is none. If this is the only reason to have paramedics (mortality rates decrease), then it is not worth having paramedics in many cases. Many of us however believe that there is more to this job than just "life saving" however the additional benefits that paramedics provide are not well researched. Things like pain control and symptom relief do not save lives. Yet according to the rest of healthcare, they matter and I tend to agree. We just don't seem to care. 

Also an "EMT knowing ALS" would be considered an Intermediate or Paramedic (maybe an Advanced if you really stretch the definition). If an EMT wants to be trained in ALS, they can go to school for that...


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## DragonClaw (Apr 15, 2019)

Tigger said:


> Indeed this research has been done at times. However the general end goal is show mortality benefit, of which for many patients who receive paramedic care there is none. If this is the only reason to have paramedics (mortality rates decrease), then it is not worth having paramedics in many cases. Many of us however believe that there is more to this job than just "life saving" however the additional benefits that paramedics provide are not well researched. Things like pain control and symptom relief do not save lives. Yet according to the rest of healthcare, they matter and I tend to agree. We just don't seem to care.
> 
> Also an "EMT knowing ALS" would be considered an Intermediate or Paramedic (maybe an Advanced if you really stretch the definition). If an EMT wants to be trained in ALS, they can go to school for that...



I agree there's more to life saving,  but compared to pain control, it's not as big a priority in that moment.  I mean,  a bruise due to a fall,  vs the guy with sucking chest wound  because he got shot. Of course,  the frequency of occurrences are probaby not even in the same category,  so maybe I'm talking myself into a corner.

And regarding that,  I almost mentioned the same thing,  with the exception of maybe a little more training for BLS. I mean,  from what I understand things like BGL and Epi are pretty easy, so why not make sure that's standard for BLS? From reading, (not on experience,  correct me if I'm wrong), even a needle decompression or a placing 12-lead shouldn't be / that/ hard.


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## wtferick (Apr 15, 2019)

DragonClaw said:


> Is that some sort of malpractice if he was harmed by the delay?


This scenario wouldn't hold up on court.


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## mgr22 (Apr 15, 2019)

DragonClaw said:


> And regarding that,  I almost mentioned the same thing,  with the exception of maybe a little more training for BLS. I mean,  from what I understand things like BGL and Epi are pretty easy, so why not make sure that's standard for BLS? From reading, (not on experience,  correct me if I'm wrong), even a needle decompression or a placing 12-lead shouldn't be / that/ hard.



A misconception about paramedics among some EMTs is that meds and procedures are the most significant differences between those two levels. That's not true. The main differences are what paramedics are expected to know and how they're supposed to apply that knowledge. To stick with one of your examples, giving epi is easy, but knowing the subtleties involving risks, benefits, and options is much more challenging.


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## rescue1 (Apr 15, 2019)

Tigger said:


> Indeed this research has been done at times. However the general end goal is show mortality benefit, of which for many patients who receive paramedic care there is none. If this is the only reason to have paramedics (mortality rates decrease), then it is not worth having paramedics in many cases. Many of us however believe that there is more to this job than just "life saving" however the additional benefits that paramedics provide are not well researched. Things like pain control and symptom relief do not save lives. Yet according to the rest of healthcare, they matter and I tend to agree. We just don't seem to care.
> 
> Also an "EMT knowing ALS" would be considered an Intermediate or Paramedic (maybe an Advanced if you really stretch the definition). If an EMT wants to be trained in ALS, they can go to school for that...



There are studies that show mortality benefit to ALS, mostly chest pain/cardiac patients and respiratory patients. 

I agree with you about symptom relief, though I'm of the mind that most of the basic symptom relief meds (ondansetron, diphenhydramine, ketorolac, acetaminophen, etc) should be provided at the BLS level (though not at the current BLS level of education).


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## DragonClaw (Apr 15, 2019)

mgr22 said:


> A misconception about paramedics among some EMTs is that meds and procedures are the most significant differences between those two levels. That's not true. The main differences are what paramedics are expected to know and how they're supposed to apply that knowledge. To stick with one of your examples, giving epi is easy, but knowing the subtleties involving risks, benefits, and options is much more challenging.





rescue1 said:


> There are studies that show mortality benefit to ALS, mostly chest pain/cardiac patients and respiratory patients.
> 
> I agree with you about symptom relief, though I'm of the mind that most of the basic symptom relief meds (ondansetron, diphenhydramine, ketorolac, acetaminophen, etc) should be provided at the BLS level (though not at the current BLS level of education).


 That's what I meant when I said EMT B having ALS skills.  More tools,  but knowing how and when to use them or not use them is just as important.


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## rescue1 (Apr 15, 2019)

DragonClaw said:


> That's what I meant when I said EMT B having ALS skills.  More tools,  but knowing how and when to use them or not use them is just as important.




Like @Tigger said earlier, that's the model that most Commonwealth countries use (Canada, UK, Australia, NZ). They have a basic paramedic level which operates on what we'd call AEMT (which is usually a 3 year degree), and then advanced paramedics who do what we'd call ALS. 

I'd be all for this system, but so far no one wants to pay for it haha.


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## SentinelGary (Apr 17, 2019)

I personally like the idea of BLS trained with some ALS skills, mainly because that’s what my service does. We are spoiled in that Kansas has a pretty wide scope for all levels of prehospital care, and my service allows us the full scope. It works very well _here_, because as volunteers we don’t always know if we are leaving with BLS or ALS, and like I said before: in a rural service, ALS is crucial. 

That’s my two cents anyways.


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## Tigger (Apr 18, 2019)

We should not just be giving EMTs more and more "skills" without changing the educational process. Colorado essentially allows EMTs to practice at the AEMT level through waivers and add on classes, for a total of maybe 30 extra hours. The standard for these classes is poorly defined and there are minimal CE requirements for them. To top it off, we don't even know if it there is benefit to a lot of this. Do I think that EMTs placing SGAs is a good thing and helps patients? Yup sure do. How about EMTs starting IVs? Who knows? We never looked. It makes my job easier, but do I want an EMT who runs 30 calls a years to be starting IVs and pushing D50? I'm not sure.

It's not all about skills. Too often EMS adds things because it makes the providers feel good.


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## DrParasite (Apr 18, 2019)

I would love for EMTs to be able to do more.  Give benedryl, insert a SGA, give albuterol for wheezing, check BGL and SQ epi would be a great start (NJ didn't allow any of that when I was up there).  Clear C-spine in the field would be another (rumor has it we can do that in the next 12 months).

I would LOVE to give IM zofran.  PO/SL is nice, but IM is even nicer (administration is just like giving Epi), and makes patients feel so much better.  Nothing to do with providers feeling good, that would help the patients.

Start IVs?  ehhhhh, maybe if they are on an ALS unit and partnered with a paramedic, otherwise, a (relatively) lot of training for low reward.  Ditto intubation.  Nice to have, but does it really benefit the patient?  ehhhh.

But I also agree that the education is lacking.


SentinelGary said:


> but I know there have been patients where our BLS crew had no idea what to do, and when ALS was called they were able to intervene. One example is the use of D50, I suppose. The real difference is education.


There is a HUGE difference between having no idea what to do, and knowing what is needed but being unable to provide the intervention.  If you have a patient with a BGL of 30, and then have no idea what to do, then their initial EMT training failed them.  

However, if they recognize that they identify the issue, recognize they can't fix the issue, and package the patient for transport, so when the ALS unit arrives, all they need to do is administer D50, and then the patient can either be transported or not (depending on local protocols, reason sugar dropped, etc), well, that's a different story.

If you need a medic to hold your hand and tell you what to do, than that's your issue.  Not every EMT is like that.  In fact, many tiered EMS system  have EMTs like that, because you don't have ALS with you on every call, so you are expected to know how to do your job.


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## rescue1 (Apr 18, 2019)

I think the national standard for AEMT covers about 90% of what people would find useful on the vast majority of EMS runs. I think it's something like: albuterol, epinephrine IM, glucagon/dextrose, naloxone, nitrous oxide, nitro/ASA, plus IV/IO access + fluids, CPAP, and supraglottic airways. The only things I would add would be diphenhydramine and maybe Zofran, like @DrParasite said. 
BGL and clearing c-spine should be a given just for being on an ambulance but I know some places are very behind. 
I wish the AEMT class was longer than 500 hours but I think it's a whole lot better than EMT-B class. 

Things like cardioversion/pacing, ACLS drugs, needle decompression, etc should be reserved for paramedic level training. These are the high acuity patients that benefit from more educated providers. Same goes with intubation--I don't think there is any place for BLS intubation, and you could easily make the argument that there might not be a place for routine prehospital intubation at all. 

To disagree with DrParasite though, I don't think that we can say that people's BLS/EMT training failed them when they **** the bed, metaphorically, on calls. I was prepared for absolutely nothing after my EMT class--thanks to having some good partners and being a huge nerd who researched stuff I managed to figure everything out, but the class itself was not a strong foundation. Yes, there are going to be prodigies  who take an EMT course and immediately grasp everything, but the vast majority of people are going to need more than the basic class, and many of them will not have exposure to a good FTO system--many will start off at a crappy IFT job, or at a small town volly squad where bad habits have been passed down for generations.


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## johnrsemt (Apr 22, 2019)

At an A&R (Audit and Review) our Medical Director did years ago, a few EMT-B's asked why they weren't allowed to do Albuterol (Neb) blood glucose, SL NTG (not patients) and something else.
  Medical Director asked them what the BLS Protocol was for Cardiac Chest Pain:   it took 4 EMT-B's almost 5 minutes to get the BLS protocol right:  324 mg ASA, chewed; 02 above 95%; help pt with NTG if they have their own and it isn't expired; head for a hospital that has a cath lab and call for a medic but if you can get to the hospital faster than meeting with a medic cancel the medic and just go to the hospital.

  Doctor told them that is why he has a problem adding to their protocols


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## DragonClaw (Apr 22, 2019)

johnrsemt said:


> At an A&R (Audit and Review) our Medical Director did years ago, a few EMT-B's asked why they weren't allowed to do Albuterol (Neb) blood glucose, SL NTG (not patients) and something else.
> Medical Director asked them what the BLS Protocol was for Cardiac Chest Pain:   it took 4 EMT-B's almost 5 minutes to get the BLS protocol right:  324 mg ASA, chewed; 02 above 95%; help pt with NTG if they have their own and it isn't expired; head for a hospital that has a cath lab and call for a medic but if you can get to the hospital faster than meeting with a medic cancel the medic and just go to the hospital.
> 
> Doctor told them that is why he has a problem adding to their protocols


Fair,  _but_,   if someone isn't allowed to use a skill,  do you expect them to know it? Maybe you do for simple things.  So,  why not train them properly then ask that question again?


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## mgr22 (Apr 22, 2019)

DragonClaw said:


> Fair,  _but_,   if someone isn't allowed to use a skill,  do you expect them to know it? Maybe you do for simple things.  So,  why not train them properly then ask that question again?



I think you misunderstood: They WERE trained to treat chest pain at a BLS level, but didn't know the protocol.


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## DragonClaw (Apr 22, 2019)

mgr22 said:


> I think you misunderstood: They WERE trained to treat chest pain at a BLS level, but didn't know the protocol.


I'll see my way out and go eat my shirt.


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## DrParasite (Apr 22, 2019)

johnrsemt said:


> At an A&R (Audit and Review) our Medical Director did years ago, a few EMT-B's asked why they weren't allowed to do Albuterol (Neb) blood glucose, SL NTG (not patients) and something else.
> Medical Director asked them what the BLS Protocol was for Cardiac Chest Pain:   it took 4 EMT-B's almost 5 minutes to get the BLS protocol right:  324 mg ASA, chewed; 02 above 95%; help pt with NTG if they have their own and it isn't expired; head for a hospital that has a cath lab and call for a medic but if you can get to the hospital faster than meeting with a medic cancel the medic and just go to the hospital.
> 
> Doctor told them that is why he has a problem adding to their protocols


What did they not know?  I remember in my EMS academy/orientation for my former job, there were written exam questions about whether the proper dose for ASA was 324 or 325..... Also, do you give oxygen if their SPO2 was 94 or below, or below 95....  did they not know the 5 rights? 

I'm guessing your agency does annual competencies right?  to verify that they know what is expected of them?  and con ed to correct any deficiencies?  Looks like your agency's training officer/department has a pretty serious failure, if they haven't verified that their personnel know the proper BLS protocols.

I would also hypothesize that if your EMTs are always paired with a medic, and the medic always calls the shots and tells the EMTs what to do, what dosages to give, and when to give it, then your EMTs don't need to know any of that information, because the medic will be telling them (but will agree they should know their protocols).  Now if they don't always have a medic, and still don't know, then yes, that's a pretty serious issue, one that should be addressed by your training department.


mgr22 said:


> I think you misunderstood: They WERE trained to treat chest pain at a BLS level, but didn't know the protocol.


Well, I was trained to give activated charcoal.... and apply MAST pants.... haven't had charcoal in almost 10 years.... MAST pants in almost 20.....

But if more than one person doesn't know the protocol, and they are expected to know the protocol, that seems to be more of a system problem, vs an individual competence problem.


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## photog (Apr 22, 2019)

Here's how EMS is organized in my country. Typically it consists of five different levels.

*1. FIRST RESPONDER* (minimum of 32 hours of training)
- Usually voluntary fire departments
- Equipment: AED, oxygen, OPA, SGA (typically iGel), BVM, diagnostic tools (SpO2, BP, b-Gluk, b-Keto, temp, alco etc), normal first aid kits, vacuum splints, rescue tools etc. Some units carry p.o. glucose, EpiPen and CarboMix.
- Usually respond to most urgent calls only.
- Fire truck ("engine") or FD owned SUV / minivan equipped with mentioned equipment

*2. BLS* (either 2-3 years of second level school (combined "EMT" and "CNA") or professional firefighter school (1,5 years of which 6 months is dedicated to EMS)
- All of the above, plus: monitor-defibrillator (LifePak 15, Zoll X-Series etc), 15-lead ECG, i.v. equipment, CPAP
- Salbutamol, adrenaline, i.n. midazolam, i.n. fentanyl, iv fluids (RAC, G10%)
- Typically operate "normal" ambulances (MB Sprinters and equivalents)

*3. ALS* (Minimum of a 4-year B.Sc in emergency care -degree (combined RN + "paramedic"), usually also 1-2 years of BLS experience required)
- All of the aboce, plus a rather wide range of i.v. / i.m / s.c / inh. meds (all your typical ALS meds including opiates, ketamine, cardiac drugs, benzos, TXA, narcan, flumazenil, thrombolytics, steroids, drug infusions etc)
- TC pacing, cardioversion, intubation, i.o. drills, cric kits, ped kits etc. LUCAS and NIV (Oxylog / Hamilton) also in some units.
- Typically operate "normal" ambulances. Also one-person fly cars in some areas.

*4. FIELD SUPERVISOR* (B.Sc in emergency care + typically studies in EMS management or nowadays M.Sc in health sciences or emergency care - a total of 4-6 years)
- All of the above plus some extra meds (second line seizure drugs, more anesthetics, CyanoKit etc)
- Respirator (Oxylog or Hamilton), video laryngoscope, i-stat / Epoc, LUCAS
- Blood products in some units
- Typically respond in  fly-cars / SUV

*5. EM DOCTOR* (typically specialized either in anesthesiology & intesive care or acutology - total of 12 years)
- All of the above plus even more drugs and blood products
- Possibility for clamshell thoracotomy, thoracostomy, emergency c-cection and other surgical emergency procedures
- Typically respond in helicopters or minivans in some areas. Mostly helicopters.


That's it. The backbone of our EMS system are ambulances manned with two persons. One BLS, one ALS. Therefore most of our ambulances operate on ALS level. There are also BLS-only ambulances in larger cities that take care of the low-risk calls and also respond to high-risk calls as first responders.

I know I'm propably not completely objective, but I kind of like our 5-tier system.


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## OceanBossMan263 (Apr 24, 2019)

NY has begun to allow EMT to use CPAP, draw up and inject IM epi, and to acquire and transmit (not interpret) 12-lead EKG. The epi was mainly a response to the enormous price of auto-injectors. Each skill requires the agency to gather approval from the region and then ensure training for individual providers. 

The AEMT course has come to my region to fill some of the void left by the departure of EMT-Critical Care, but there isn't much of a market for providers at that level and it shows in the attendance. They're taught IVs, ET/combi (though my region doesn't allow the use of ET, feeling that many at that level don't come with a ton of experience), D50, and maybe a select few other drugs. No cardiology.


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## DesertMedic66 (Apr 24, 2019)

OceanBossMan263 said:


> NY has begun to allow EMT to use CPAP, draw up and inject IM epi, and to acquire and transmit (not interpret) 12-lead EKG. The epi was mainly a response to the enormous price of auto-injectors. Each skill requires the agency to gather approval from the region and then ensure training for individual providers.
> 
> The AEMT course has come to my region to fill some of the void left by the departure of EMT-Critical Care, but there isn't much of a market for providers at that level and it shows in the attendance. They're taught IVs, ET/combi (though my region doesn't allow the use of ET, feeling that many at that level don't come with a ton of experience), D50, and maybe a select few other drugs. No cardiology.


The national standard for EMTs has incorporated CPAP, Epi IM, Narcan IN/IM. A decent amount of states have already been allowing their EMTs to do the skills with more areas allowing it.


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## KingCountyMedic (Apr 24, 2019)

Our EMT's are some of the finest in the country. They do check and inject Epi, nasal narcan, ASA, assist patients with own nitro and albuterol, carry pulse oximetry, check BGL....and coming soon to a King County BLS unit near you: The iGel airway for cardiac arrest.

There is need to know and nice to know. I don't think we should cloud up an EMT's brain with more information than they can use. You need to know "sick not sick" and go from there. If you're providing high quality BLS you're already solving 90% of the worlds problems.


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## Tigger (Apr 24, 2019)

I've probably summarized this before but Colorado EMTs can (with additional training):

Start IVs and IOs (cardiac arrest for all, we have a waiver for "unresponsive patients with a low BLG" [yikes])
Hang NS and LR
D50
IV/IM/IN Narcan 
IM/IV/ODT Zofran
Provide their own Albuterol nebulizer treatments 
Draw and give IM Epi
Place supraglottic airways and use EtCO2 (colormetric or waveform) to confirm 
Obtain and transmit 12 lead EKGs
CPAP
This is really not a bad BLS scope. My EMT partner can handle lots of "sick people" and EMT first responders have access to some pretty important interventions. My issue is that we just keep adding to the IV class that EMTs take. It's now 30 hours long, but it teaches nothing but the skills. Since AEMT just adds Atrovent, Benadryl, and Glucagon along with EJs I wish we just transition to this scope but that's *gasp* too many hours.


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## DrParasite (Apr 25, 2019)

I'm not sure if that's an awesome BLS scope because they can do so much, or a scary BLS scope because they can do so much with so little education (particularly in the starting IVs, and giving all those medications via IV and IOs)


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## johnrsemt (Apr 30, 2019)

Dr Parasite:  I should have clarified:  that A&R was about 15 years ago, and was open county wide  most services there had BLS trucks (2 basics) and then ALS trucks (either Medic/Basic or 2 medics).  It did bring up a problem that the basics and some of the medics didn't know the basic protocols.
  They did do an annual protocol test:  When I did it as a basic I always took both, because the medics I worked with made me learn the ALS protocols so they could double check themselves against me.  and as a medic I always took the Basic test, so that I knew them too.
   Turned out some departments and services would let their employees take the tests open book.  So they started giving the tests at the hospitals, with doctors watching them.   Surprising how many failed them at that point.
  They started training with them a lot more, and from what I understand they don't have a problem as much  (I have been gone from there 11 years now).

   Also agree with you on the awesome BLS scope of practice:  except the IV part.   We had a medic instructor that taught his 7 year old daughter how to do IV's and she was pretty good at it;  better than her dad;   Meds and IO's would be scary with little training.


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