# Call for ALS?



## Sasha (Feb 14, 2009)

For those of you who ride a Basic/Basic 911 response truck. What kind of calls do you determine to need ALS? How do you make that determination? What parameters are set by your company? Are there complaints that automatically get an ALS response sent with them? Do you not feel that everyone needs an ALS assesment?


----------



## EMTinNEPA (Feb 14, 2009)

99% of the time, my service and ALS will get a stacked dispatch.  Anything that's potentially or definitely life threatening (major trauma, bleeding, ABC threats, altered mental status, cardiac arrest, etc., etc.) will have a stacked dispatch.  However, BLS will get dispatched alone if it's something minor such as knee pain or "an ill person".  Fire standbys also get BLS only, unless it is a confirmed working structure fire, in which case the incident will get an ALS rig as well.


----------



## Buzz (Feb 14, 2009)

Sasha said:


> For those of you who ride a Basic/Basic 911 response truck. What kind of calls do you determine to need ALS? How do you make that determination? What parameters are set by your company? Are there complaints that automatically get an ALS response sent with them? Do you not feel that everyone needs an ALS assesment?




If there's a medic unit available, the ALS crew gets sent out to a rescue call. If one's not available, they send the BLS. Once on scene, the BLS car will rarely request ALS because they could be to an ER by the time the ALS crew would be arriving on scene. (Our average transport time to an ER in this area is 7 minutes) The only time the BLS crew would request ALS is for an MVA where prolonged extrication is probable.


----------



## Sapphyre (Feb 14, 2009)

I've mentioned before, I work in the land of Johnny and Roy.  All calls get an engine/truck/quint, a squad, and and ambulance, at least.  The squad is ALS and they are dispatched at the same time we are.  The captain can cancel the squad on some calls (don't ask me which).


----------



## medic417 (Feb 14, 2009)

EMTinNEPA said:


> However, BLS will get dispatched alone if it's something minor such as knee pain or "an ill person".




UMMM what to say and how to say it.  That is stupid.  Sorry but knee pain can be indicative of many things and warrants an ALS response.  As to the ill person almost ever code I have worked was dispatched as an ill person but I guess they did not deserve an ACLS attempt to save their lives per your system.  :wacko:

Sorry every patient deserves an ALS exam.   And again in reality ALS should be the minimum of patient care on every ambulance.  Even the stubbed toe call could be masking some other real problem that at the basic level would be missed.  I have had more than one patient thats only sign/symptom with BLS exam was big toe pain that turned out to be having an acute MI.  

Now if your service chooses not to have the best which would be two Paramedics per ambulance but runs an Basic/Paramedic ambulance then after an ALS exam care could be given by the basic allowing the Paramedic to drive.  But an ALS exam is warranted on all calls.


----------



## emtfarva (Feb 14, 2009)

Calls that I would request als for:
Chest Pain
Diff Breathing
hypotension, hypertension (when comfirmed by me)
active sz
AMS
Back Pn
extended extraction


----------



## Sasha (Feb 14, 2009)

medic417 said:


> UMMM what to say and how to say it.  That is stupid.  Sorry but knee pain can be indicative of many things and warrants an ALS response.  As to the ill person almost ever code I have worked was dispatched as an ill person but I guess they did not deserve an ACLS attempt to save their lives per your system.  :wacko:
> 
> Sorry every patient deserves an ALS exam.   And again in reality ALS should be the minimum of patient care on every ambulance.  Even the stubbed toe call could be masking some other real problem that at the basic level would be missed.  I have had more than one patient thats only sign/symptom with BLS exam was big toe pain that turned out to be having an acute MI.
> 
> Now if your service chooses not to have the best which would be two Paramedics per ambulance but runs an Basic/Paramedic ambulance then after an ALS exam care could be given by the basic allowing the Paramedic to drive.  But an ALS exam is warranted on all calls.



that was exactly what i was saying in the chat last night.. where were you! jeez! (insert smiley face here... typing from pjone! but some people dont feel als is even warranted. silly us doing the extra education for nothing!


----------



## MMiz (Feb 14, 2009)

At our service the only calls that would not get a 911 ALS response for 911 calls were calls by the local jail asking for transport or psych calls.

As BLS I've requested ALS for chest pain, difficulty breathing, and wacky vitals (usually hypotensive).  Those are just things that I can't effective treat, and the patient deserves ALS.

_*Our service believed that any BLS that would warrant lights/sitens transport deserved ALS*._  If I were to get a patient in the truck and radio that I was transporting lights and siren, then it would automatically initiate an ALS intercept.  I've cancelled ALS twice due to our close proximity to the hospital (five or less minutes).


----------



## medic417 (Feb 14, 2009)

Sasha said:


> that was exactly what i was saying in the chat last night.. where were you! jeez! (insert smiley face here... typing from pjone! but some people dont feel als is even warranted. silly us doing the extra education for nothing!




Yes we wasted our time and money as we all know basics save Paramedics.:wacko:  That would be like letting a blind person guide a seeing person through traffic.


----------



## Shishkabob (Feb 14, 2009)

medic417 said:


> That would be like letting a blind person guide a seeing person through traffic.



Yes, that's the proper attitude!



/sarcasm


----------



## Sparky79 (Feb 14, 2009)

I think I'm just gonna tear up my useless Basic cert and see if McDonalds is hiring


----------



## medic417 (Feb 14, 2009)

Sparky79 said:


> I think I'm just gonna tear up my useless Basic cert and see if McDonalds is hiring



Probably make more money and might actually use your basic skills more there doing CPR and helping choking people.


----------



## ffemt8978 (Feb 14, 2009)

I'll post the same scenario that I did in the chat room last night, and you can explain to me how it warrants an ALS assessment.

A few years ago we had to transport a patient who was stung by a non-poisonous scorpion that was smaller than a dime.  The stinger did NOT make it through the skin, and there was absolutely no bleeding, swelling, or anything else wrong with this patient.  The only reason we transported was that the child's mother absolutely insisted on going to the hospital.

So why does this patient warrant an ALS assessment?


----------



## Sparky79 (Feb 14, 2009)

medic417 said:


> Probably make more money and might actually use your basic skills more there doing CPR and helping choking people.



You're probably right! Luckily, I'm a full time electrician and an emt part time. I would make about 1/3 of what I make as an electrician if I was a full time basic. I don't know how people survive on that.

I do more first aid on construction sites as an electrician than when I'm doing shifts on the ambulance as an emt.


----------



## medic417 (Feb 14, 2009)

ffemt8978 said:


> I'll post the same scenario that I did in the chat room last night, and you can explain to me how it warrants an ALS assessment.
> 
> A few years ago we had to transport a patient who was stung by a non-poisonous scorpion that was smaller than a dime.  The stinger did NOT make it through the skin, and there was absolutely no bleeding, swelling, or anything else wrong with this patient.  The only reason we transported was that the child's mother absolutely insisted on going to the hospital.
> 
> So why does this patient warrant an ALS assessment?




Prior to EMS arrival you do not know all those facts.  Plus who says it was not poisonus are you a scorpion expert?  Some scorpions look very similiar to one another one just hurts like heck the other injects some pretty serious poison.  So you actually are responding to a possibly serious event so should be ALS responding.  Patient is found.  And yes a scorpion expert arrives as you do confirms not poisonous.  After ALS exam no problem found not even a true sting.  So guess what we do not transport regardless of mothers demand.  

But ALS was needed to rule out and to be there if it turned out legit.  What would a basic crew do if airway closing from the toxins?  Call ALS so ALS should have been first response to be safe.


----------



## ffemt8978 (Feb 14, 2009)

There are no poisonous scorpions in my state, unless they're in a zoo.

And if we had waited for ALS to arrive just to assess this patient, it would have been an hour for them to show up.  But you mentioned that you would have not transported the patient, regardless of the mother's demands.  Legally, we can't refuse to transport a patient.  We can do our best to talk them out of it, but if they insist then they get the ride.

But just to make sure that I understand this, you're saying that every patient deserves an ALS assessment to rule out anything because we don't know what we're going to based upon dispatch information.  Yet you wouldn't take them to the hospital, so that a definitive diagnosis/rule out can be accomplished using appropriate diagnostic equipment such as labs.  I'm curious as to what diagnostic equipment you would have used on this patient that was different than what I had access to at the time.


----------



## emtfarva (Feb 14, 2009)

emtfarva said:


> Calls that I would request als for:
> Chest Pain
> Diff Breathing
> hypotension, hypertension (when comfirmed by me)
> ...


 
drug OD
hypoglycemia


----------



## medic417 (Feb 14, 2009)

ffemt8978 said:


> There are no poisonous scorpions in my state, unless they're in a zoo.




In todays world we can not say that for sure.  With people and packages traveling all over the world we are seeing more and more insects that are not native to the USA.  So there is always potential that one could be there.  Also even the non poisonous do cause some people to have severe allergic reactions.  Again an ALS call.


----------



## volff21 (Feb 14, 2009)

sasha said:


> for those of you who ride a basic/basic 911 response truck. What kind of calls do you determine to need als? How do you make that determination? What parameters are set by your company? Are there complaints that automatically get an als response sent with them? Do you not feel that everyone needs an als assesment?




as an emt in the state of pa not to long ago we were able to determine following state protocol on whether or not a pt was als or bls criteria.anymore if we make that determination and cancel als they tend to request an audit of our report.wont be much longer and an emt will just be an abbreviation for drivers.


----------



## volff21 (Feb 14, 2009)

But then again if you let them board and dont feel the need to ride it cover your a**


----------



## emtfarva (Feb 14, 2009)

Dispatched as: Emotional distress

UOA found 60 y/o f standing outside a store. Pt is CAOx3. Pt's cc is "the world is going to end by nuclear war". Per Tauton fire pt has been calling 911 all day. also per fire Pt has long psych hx with MR. When the Pt was asked what made her feel differently today "it just feels wrong and my ex-husband is out to get me." VS wnl. transported to hosp. At hosp nurse observed that the pt was having AH. I looked at the pt's hx and found no medical problems other than psych.

No als needed here.


----------



## ffemt8978 (Feb 14, 2009)

medic417 said:


> In todays world we can not say that for sure.  With people and packages traveling all over the world we are seeing more and more insects that are not native to the USA.  So there is always potential that one could be there.  Also even the non poisonous do cause some people to have severe allergic reactions.  Again an ALS call.



I was editing my post when you posted this, so if you want you can go back and address the rest of the post.

And while we don't have true scorpion experts on our dept., we have enough local residents who recognized that the scorpion was non-poisonous.  In the 50 or so years this community has been here, there has never once been a poisonous scorpion found.

But by your line of reasoning, it should be an ALS assessment just in case it is some obscure problem that is being masked by something else.  So if every patient deserves an ALS assessment, shouldn't they be getting the best assessment possible?  If so, then every patient needs to be taken to a hospital where a doctor can assess them.


----------



## medic417 (Feb 14, 2009)

emtfarva said:


> Dispatched as: Emontional distress
> 
> UOA found 60 y/o f  standing outside a store. Pt is CAOx3. Pt's cc is "the world is going to end by nuclear war". Per Tauton fire pt has been calling 911 all day. also per fire Pt has long pysch hx with MR. When the Pt was asked what mad her feel differntly today "it just feels wrong and my ex-husband is out to get me." VS wnl. transported to hosp. At hosp nurse observed that the pt was having AH. I looked at the pt's hx and found no medical problems other than psych.
> 
> No als needed here.



I disagree.  Her mental state might warrant ALS more than many calls.  Plus if extemely emotional what can a basic do.  ALS can at least sedate if need be to help her relax.  Plus with her mentioning here husband out to get her did you look for signs of abuse.  Just because someone crys wolf a million times does not mean that the million and one time is not real.  Psych patients actually need even higher level than a Paramedic but since that is not currently available in the field they deserve at minimum an ALS response.


----------



## emtfarva (Feb 14, 2009)

medic417 said:


> Prior to EMS arrival you do not know all those facts. Plus who says it was not poisonus are you a scorpion expert? Some scorpions look very similiar to one another one just hurts like heck the other injects some pretty serious poison. So you actually are responding to a possibly serious event so should be ALS responding. Patient is found. And yes a scorpion expert arrives as you do confirms not poisonous. After ALS exam no problem found not even a true sting. So guess what we do not transport regardless of mothers demand.
> 
> But ALS was needed to rule out and to be there if it turned out legit. What would a basic crew do if airway closing from the toxins? Call ALS so ALS should have been first response to be safe.


Any PT or Pt's parent that requests they be brought to the Hosp has to be brought to the Hosp. whatever you think it is the law.


----------



## Shishkabob (Feb 14, 2009)

Why not just call for a doctor to come and assess?  I mean, if you want an advanced assessment for EVERY call, might as well go all the way, right?


----------



## emtfarva (Feb 14, 2009)

medic417 said:


> I disagree. Her mental state might warrant ALS more than many calls. Plus if extemely emotional what can a basic do. ALS can at least sedate if need be to help her relax. Plus with her mentioning here husband out to get her did you look for signs of abuse. Just because someone crys wolf a million times does not mean that the million and one time is not real. Psych patients actually need even higher level than a Paramedic but since that is not currently available in the field they deserve at minimum an ALS response.


I live and work In MA, ALS can only do what a Basic can do for a psych PT. THEY HAVE NO PROTOCOLS FOR CHEMICAL RESTRAINTS. also her ex-husband was dead, btw.


----------



## medic417 (Feb 14, 2009)

ffemt8978 said:


> There are no poisonous scorpions in my state, unless they're in a zoo.
> 
> And if we had waited for ALS to arrive just to assess this patient, it would have been an hour for them to show up.  But you mentioned that you would have not transported the patient, regardless of the mother's demands.  Legally, we can't refuse to transport a patient.  We can do our best to talk them out of it, but if they insist then they get the ride.
> 
> But just to make sure that I understand this, you're saying that every patient deserves an ALS assessment to rule out anything because we don't know what we're going to based upon dispatch information.  Yet you wouldn't take them to the hospital, so that a definitive diagnosis/rule out can be accomplished using appropriate diagnostic equipment such as labs.  I'm curious as to what diagnostic equipment you would have used on this patient that was different than what I had access to at the time.



OOPs my bad I jumped to the conclusion that you knew accurately that the skin was not penetrated.  And also I forgot that some toxins can be absorbed through the skin.  So yes as a caution might be advisable to transport.  But I am allowed to deny transport.  In a case like this I would actually just stay on scene with them for a few minutes to observe that no reactions were taking place.  

But yes ALS should be dispatched to all calls.  Way to many calls for a BP check turn into being full blown acute MI's.  

And while a doctor on every ambulance would even be better a properly educated ALS team should be able to treat and release and or determine proper transport location even if only to a local clinic or to the big cardiology hospital.  And by doing this we could free up the congestion that is the current USA emergency system.


----------



## medic417 (Feb 14, 2009)

emtfarva said:


> Any PT or Pt's parent that requests they be brought to the Hosp has to be brought to the Hosp. whatever you think it is the law.




Please produce that law.  Not your local protocol but that law.  I have yet to see any state/federal law that says you must transport all that request it.  There are laws that say you can not deny emergency stabilization, but to this point I have seen no law say that you can not deny transport to non emergent patients.  I am not going to say it does not exist but I have in all my years have any one produce the law when I ask.  I have had several produce protocols but not one law.


----------



## Shishkabob (Feb 14, 2009)

medic, I'm all for more education, and I want to agree with you, but I can't for one simple reason;

The way you phrase it, and the way you go about it, steps on peoples toes with the assumption that basics don't know anything, when that is just not true.




> Please produce that law. Not your local protocol but that law. I have yet to see any state/federal law that says you must transport all that request it.



Just one off the top of my head: Abandonment.


----------



## ffemt8978 (Feb 14, 2009)

medic417 said:


> Please produce that law.  Not your local protocol but that law.  I have yet to see any state/federal law that says you must transport all that request it.  There are laws that say you can not deny emergency stabilization, but to this point I have seen no law say that you can not deny transport to non emergent patients.  I am not going to say it does not exist but I have in all my years have any one produce the law when I ask.  I have had several produce protocols but not one law.



I'm still looking for the actual law, but you may want to check out page 408 of this book
http://books.google.com/books?id=uj...C9c&sig=wrB3f1v6ogs8GSFpK_UCodyMMqA#PPA408,M1

It may not be against the law where you live, but not every part of the country has laws concerning EMS-Initiated Refusal of Transport.


----------



## medic417 (Feb 14, 2009)

Linuss said:


> medic, I'm all for more education, and I want to agree with you, but I can't for one simple reason;
> 
> The way you phrase it, and the way you go about it, steps on peoples toes with the assumption that basics don't know anything, when that is just not true.
> 
> Just one off the top of my head: Abandonment.



Actually it does not fall under abandonment.  Nice try though.

I do apologize if I come accross harshly.  My gripe is basics going the other extreme that they know everything.  The frustration is a two way street.


----------



## Shishkabob (Feb 14, 2009)

And mine lays with medics that think they know everything and that are the only ones that can better EMS... guess we're on the same page  ^_^


I don't act like I know everything, and I know I don't, but I don't like it when someone bashes my level of education, or in their view lack thereof, simply because of a single certification, and not base it on any of my other education.


THAT is what irks me and why I always jump in these threads.  It's not because I think basics should do everything, but because they are making a blanket statement about ALL basics.


----------



## medic417 (Feb 14, 2009)

ffemt8978 said:


> I'm still looking for the actual law, but you may want to check out page 408 of this book
> http://books.google.com/books?id=uj...C9c&sig=wrB3f1v6ogs8GSFpK_UCodyMMqA#PPA408,M1
> 
> It may not be against the law where you live, but not every part of the country has laws concerning EMS-Initiated Refusal of Transport.



Yes that is a good read.  There is much liability involved in denying patients and even in accepting a patient refusal.  And even in my system with the right to deny you have som many checks involved often it is just easier to transport most patients.  

As to the law I would just like to see the laws.  I have had the law says thrown at me since I first got in EMS yet no one from any state has shown me a law that states I can not deny transport to someone that does not need it.  In fact the only laws I have found during research actuall deal with charging patients with 911 abuse for calling for no real reason.


----------



## ffemt8978 (Feb 14, 2009)

And that's the same reason I jump in...blanket statements with absolutes are just an invitation/challenge for me.  

Just to be clear, I'm all for an all ALS EMS system nationwide...I just feel that it will never happen because of a variety of factors that nobody wants to address.  Things like costs, skills maintenance, proficiency, and CME's aren't being addressed by the "Everyone Needs ALS" group.


----------



## medic417 (Feb 14, 2009)

Linuss said:


> And mine lays with medics that think they know everything and that are the only ones that can better EMS... guess we're on the same page  ^_^
> 
> 
> I don't act like I know everything, and I know I don't, but I don't like it when someone bashes my level of education, or in their view lack thereof, simply because of a single certification, and not base it on any of my other education.
> ...



Linuss the majority of basics have no medical training besides the two week course, no matter how long it is stretched out.  Yes there a few that have degrees in other fields.  And there are even fewer still that have degrees or certifications in other medical fields.  

And as someone else pointed out many Paramedics from diploma mills actually are not very educated but it is still a lot more than the 2 week basic course.  Diploma mills need to be closed but certain groups are fighting to keep them open and to keep all education at a minimum and fast.  

In a perfect world the basic would only be a first responder to assist Paramedics on scene with lifting andpackaging patients.  It would also allow the basic to be the third member of a dual paramedic crew while getting their paramedic degree.  

Linuss I was a basic many years and considered to be one of the best by all that worked with me.  I was the partner that the Paramedics wanted as I could handle my responsibilitys and because I to was educated besides my basic I could assist them and even be ahead of them preparing what they needed next.  So yes I did get offended when talked down about.  But Now I really see how much I was lacking and even how many patients suffered as often as a basic I was the highest level of care available.  I never applied for a job as a basic.  I was pursued by those that knew me and based on reputation.  That still goes now at the higher level.  

Again sorry if I seem harsh.  I just want to get people to start thinking and to put patients first not our egos.  And sadly that means patients deserve at least one Paramedic to respond as they in the largere scheme know more medicaly than the basics so are more likely to catch a problem that a basic could miss.


----------



## BossyCow (Feb 14, 2009)

I would dearly love to have ALS available for all patients. But it's not a reality for me in the forseeable future. I am by protocol told to call for ALS support on all altered LOC, chest pain, ABD pain and multi-system trauma calls. About 50% of the time I call for ALS support the ALS rig is unavailable or not able to meet with us in under 45 minutes to an hour. 

With a critical pt we apply a bolus of diesel therapy and hope an ALS unit breaks free from their current call or transport soon enough to meet up with us enroute. Since the area covered by our ALS system isn't able to afford a decent medic coverage, they often double up on calls, with ALS transports to Seattle hospitals, it often leaves us without an ALS rig available to meet our pt. 

In the meantime, we give o2, assist with neb treatments, we can combi-tube, start an IV, splint fxs, control bleeding, and get the pt to the ER. 

Is this limited? You betcha! Is it probably inadequate for the needs of many of our pts? Certainly! But it is reality for many of us. So regardless of 'should' we have ALS, we don't. This is the system in which many of us live and work. So telling us that we should do something that is completely and totally a wish list is pointless. Unless you are going to pass me that magic wand of unlimited funding or the cloak of universal ALS availability.. could we just answer the question of the original poster about what the protocols are?


----------



## medic417 (Feb 14, 2009)

Actually this thread has evolved into a great discussion that gets everyones passions into play and gets all to start thinking regardless of level.


----------



## BossyCow (Feb 14, 2009)

medic417 said:


> Actually this thread has evolved into a great discussion that gets everyones passions into play and gets all to start thinking regardless of level.



Sure, and instead of providing information for those of us without the option of ALS support, or with limited ALS response, it seques into an 'ALS for everyone' chest thumping session. Pointless... if you want to participate in one of those... there are a bazillion threads already dedicated to that point. But to take a thread in the BLS section of the forum and use it to toot that same tired old horn that is nothing but a pipe dream to many of us, is really tiresome, boring and repetitive.


----------



## medic417 (Feb 14, 2009)

BossyCow said:


> Sure, and instead of providing information for those of us without the option of ALS support, or with limited ALS response, it seques into an 'ALS for everyone' chest thumping session. Pointless... if you want to participate in one of those... there are a bazillion threads already dedicated to that point. But to take a thread in the BLS section of the forum and use it to toot that same tired old horn that is nothing but a pipe dream to many of us, is really tiresome, boring and repetitive.



Actually Bossy I have provided many ideas to you in the past and you griped at me everytime.  So I refuse to be drawn into that with you.  Have a nice day.


----------



## Shishkabob (Feb 14, 2009)

Aww man you edited it :sad:

Always ruining my fun!


----------



## ffemt8978 (Feb 14, 2009)

Linuss said:


> Aww man you edited it =(



Dang right I did


----------



## Shishkabob (Feb 14, 2009)

Man ffemt, you're so "boosy".


----------



## medic417 (Feb 14, 2009)

Linuss said:


> Aww man you edited it :sad:
> 
> Always ruining my fun!




What did I misspell?  My keyboard is acting up again. lol  Really seriously.


----------



## Shishkabob (Feb 14, 2009)

medic417 said:


> What did I misspell?  My keyboard is acting up again. lol  Really seriously.



You said boosy instead of bossy. 


Yea.. I'm immature, so what.


----------



## medic417 (Feb 14, 2009)

Linuss said:


> You said boosy instead of bossy.
> 
> 
> Yea.. I'm immature, so what.



OOPS.  My bad.h34r::blush:


----------



## Veneficus (Feb 14, 2009)

*perspective*

I know for the past 20 or so years we like to argue ALS vs. BLS and while we all have our opinions on what is better and why, I wonder:

What is BLS?

What is ALS?

a certification? a set of skills? a knowledge base?

None of our EMS titles are even equal state to state, to say nothing of the significant part of the world that requires a 4 year degree.

I could list off examples for hours that are grey areas at least. 

What if a nurse has a part time job as a basic? Is his knowledge base less than ALS?

If a BLS provider stabs somebody with an epi pen is that ALS?

In my home state the treatment for a scorpion sting is a moot point, there are none. (except at the zoo, where they have their own people to help who know far more about it than I ever will) At the same time, treatment for environmental effects like hyper/hypothermia are both everyday occurrences.

In my home town GSWs are not if, but how many. Providers are quite accustomed to them.

What if the IV opioid abusing, chemotherapy, dialysis patient from another country, who is noncompliant with his meds and was bitten by an indigenous spider at an airport somewhere in his travels that day with 3 lay overs suddenly goes unresponsive?

Is that an ALS call? A BLS call? does it really matter?


----------



## medic417 (Feb 14, 2009)

Veneficus said:


> IIs that an ALS call? A BLS call? does it really matter?



Actually patient care is the priority but the way the USA is set up causes this division.  If the minimum education was raised and the number of levels was dropped to one possibly 2 nationwide we might finally make progress.


----------



## Summit (Feb 14, 2009)

I made it so ALS response is always requestsed (if available, both from our service and other services since ALS isn't always assured). The other service's ALS is only stood down by BLS if BLS on scene can make a solid judgment that ALS is not required... which basically means assessment of a stable patient with isolated nondistracting trauma to a limb not requiring pain control or immobilized transport... or a patient with no discovered medical issues or complaints at all. Otherwise ALS continues in to assess and possibly treat. ALS and BLS can certainly discuss over the radio and make a determination that ALS is not required.


----------



## medic417 (Feb 14, 2009)

Summit said:


> ALS is only stood down if an EMT-B can make a solid judgment that ALS is not required... which basically means assessment of a stable patient with isolated nondistracting trauma to a limb not requiring pain control or immobilized transport... or a patient with no discovered medical issues or complaints at all.



Basically only if they want a free ride to lunch at the hospital cafe'.


----------



## Summit (Feb 14, 2009)

medic417 said:


> Basically only if they want a free ride to lunch at the hospital cafe'.



We only take them to the trail head where they will always find an ALS ambulance. 

Certainly ALS from another agency can discuss with BLS on site as to whether response is needed since committing another agency's medic for several hours of tromping around a mountainside is a decision that affect the rest of the areas EMS response system. Of course this requires that ALS provider to know and trust the assessment skills of that BLS provider.


----------



## CAOX3 (Feb 14, 2009)

medic417 said:


> UMMM what to say and how to say it.  That is stupid.  Sorry but knee pain can be indicative of many things and warrants an ALS response.



Ok list some.  

And lets not insult providers by squaking about how knee pain, tooth aches and finger nail pain can be indicative of a cardiac event.

If it walks like a duck, talks like a duck its usually a duck.  

However if your BLS personel cant competently assess a patient that a possible cardiac event is present,  you are spot on they shouldnt be responding to emergencies.

This is discussion is headed in a familiar direction.

By the way the original poster stated what reasons BLS providers would call for ALS intercepts.  

Not should every emergency call be an ALS response.


----------



## VentMedic (Feb 14, 2009)

CAOX3 said:


> Ok list some.
> 
> And lets not insult providers by squaking about how knee pain, tooth aches and finger nail pain can be indicative of a cardiac event.
> 
> ...


 
I guess you missed the section about how women may present with cardiac problems. There was also a good article posted on this forum in the news section although the thread was about someone being offended by the words ambulance driver which distracted from a serious article.

Unfortunately without an ECG, many serious cardiac problems might be missed and even that is no guarantee. 

Knee pain, especially if it is on the on posterior region can be extremely serious. The fact that you do not recognize some of these things as symptoms of more serious conditions does concern me and definitely makes medic417's point. It is the knowledge of many different pathologies and not just the few learned in an EMT-B course that must be considered. If all diagnoses fit into just the categories listed in just the EMT or even EMT-P book, medicine would really be so simple and not the complex beast it truly is.

How many precious minutes are wasted by first sending a BLS truck to have a little look before calling frantically for ALS? How many lives could have had a better chance for quality of life or even life if it was an all ALS 911 system?  Every U.S. citizen deserves access to quality medicine and not this fragmented BLS/ALS stuff.  EMS has gotten to the point of justisfying its inadequacies to preserve the minimum standard of care as being adequate medicine for the people.


----------



## triemal04 (Feb 14, 2009)

VentMedic said:


> I guess you missed the section about how women may present with cardiac problems. There was also a good article posted on this forum in the news section although the thread was about someone being offended by the words ambulance driver which distracted from a serious article.
> 
> Unfortunately without an ECG, many serious cardiac problems might be missed and even that is no guarantee.
> 
> ...


For the betterment of all, and since CAOx3 asked and you ignored it, perhaps you could explain what issues knee pn can be indicative of, and posterior knee pn in particular, as well as covering what treatements will be done by a paramedic vs a basic.  This way someone may actually be able to learn something from this thread beyond the fact that many people here, at ALL levels, are way to full of themselves.


----------



## medic417 (Feb 14, 2009)

CAOX3 said:


> However if your BLS personel cant competently assess a patient that a possible cardiac event is present,  you are spot on they shouldnt be responding to emergencies.



Not to be rude but many cardiac events occur w/o hardly any outward appearance.  You need an ALS exam to even begin to rule in cardiac.  Just because they look fine and vitals look fine doesn't mean they are. 

Now the text book MI chest pain, Left arm  and neck pain, moist pale skin.  Even a monkey could be trained to learn that is bad.  But someone educated would know most patients don't present like the text book. 

And OP asked when would you call ALS.  Some of us are just showing maybe you should be calling more often if you work in a broken system that still sends BLS only ambulances out.


----------



## triemal04 (Feb 14, 2009)

medic417 said:


> Not to be rude but many cardiac events occur w/o hardly any outward appearance.  You need an ALS exam to even begin to rule in cardiac.  Just because they look fine and vitals look fine doesn't mean they are.
> 
> Now the text book MI chest pain, Left arm  and neck pain, moist pale skin.  Even a monkey could be trained to learn that is bad.  But someone educated would know most patients don't present like the text book.
> 
> And OP asked when would you call ALS.  Some of us are just showing maybe you should be calling more often if you work in a broken system that still sends BLS only ambulances out.


For the betterment of all, and since CAOx3 asked and you ignored it, perhaps you could explain what issues knee pn can be indicative of, and posterior knee pn in particular, as well as covering what treatements will be done by a paramedic vs a basic. This way someone may actually be able to learn something from this thread beyond the fact that many people here, at ALL levels, are way to full of themselves.

Yes, this also applies to you.


----------



## CAOX3 (Feb 14, 2009)

Let me expand on my thought here.  Every system needs to be taylored to its needs.  ALS and BLS can and do succesfully work together in many systems.  

My belief is in a large Urban system that I have experience with,  is there is no need to have ALS responses to every EMS call.  The majority of these calls are and will always be BLS in nature. Truthfully the majority are cabulance in nature.

A competently trained BLS provider will have no problem handeling 95% of these calls.  The other 5% are handeled by highly educated and experienced ALS providers who do not spend there whole day carting around every Tom, **** and Harry who thinks finger pain from slamming it in a car door requires a full EMS response.

When they are summoned and they do have predetermined compalints they respond to.  They institute proffesional, NEEDED and warrented care.

The benefits of these systems are you dont get tired, burn out, rather be somwhere else ALS providers who have been humping drunks (not CVA or diabetics)and lonely old ladies all day.  You get seasoned, educated and experienced ALS providers that do nothing else then responding to and treat ALS pts.

The ALS providers care for ALS pts, they use and refine their skills by using them on a daily basis, not on a monthly basis, which is where problems arise.

The other side is you have EMTs that gain valued experience and along with continued education become those seasoned, educated and experienced ALS providers of the future.

Seems like a win win situation to me.   Flooding a system with ALS providers is not always answer.


----------



## VentMedic (Feb 14, 2009)

triemal04 said:


> For the betterment of all, and since CAOx3 asked and you ignored it, perhaps you could explain what issues knee pn can be indicative of, and posterior knee pn in particular, as well as covering what treatements will be done by a paramedic vs a basic. This way someone may actually be able to learn something from this thread beyond the fact that many people here, at ALL levels, are way to full of themselves.


 
Honestly!  


You are a supposedly a Paramedic who should be just as capable of explaining this also.  

You have already tossed your insult with the "full of themselves" remark.
So no, I am not going to waste anymore of my time typing out everything for you.  And don't bother PMing me with more of your insults and profanity either.   If you had an ounce of credibility or sincerity, I wouldn't mind, but you don't have either.


----------



## Veneficus (Feb 14, 2009)

CAOX3 said:


> Ok list some.
> 
> And lets not insult providers by squaking about how knee pain, tooth aches and finger nail pain can be indicative of a cardiac event.
> 
> ...





DVT, Gullian-Barre,local tissue ischemia, osteomalasia, sickle cell crisis, and tick borne typhus, are serious conditions that may present with lower leg/ knee pain.

Toothaches could be unusual cardiac presentation, sepsis, menigitis, and acute tosilitis. Depending on certain crainial nerve involvement could also be unusual stroke presentation due to compression. 

Fingernail pain could be a sign of scurvey or another collagen forming pathologies, in addition local compartment syndromes from infection, particularly from dog and human bites. Oh and sickle cell again. 

Places I have worked nobody was dispatched to knee pain. It usually came in as a "general malaise" or "orthopaedic injury" which always should carry high suspicion of a train  wreck. Especially when the caller is withholding information from the dispatcher as in cases of rape or other genitalia issues.

Furthermore EMS is not only about saving lives, but limbs too. Western medicine in general is about return to function.


----------



## VentMedic (Feb 14, 2009)

CAOX3 said:


> A competently trained BLS provider will have no problem handeling 95% of these calls.


 
Explain "competently trained" as it stands for the 110 hour EMT-B.


----------



## medic417 (Feb 14, 2009)

VentMedic said:


> Explain "competently trained" as it stands for the 110 hour EMT-B.



My thoughts exactly.  

Veneficus did list a number of the possible problems that could be indicated by what many a BLS provider would dismiss and sadly so would many diploma mill paramedics.  

If BLS only responded nothing really could be provided to help those that rapidly crash.  If ALS responded many possible interventions could be started that might get the patient to the hospital with a chance of leaving the hospital alive and basically intact.


----------



## Veneficus (Feb 14, 2009)

VentMedic said:


> Explain "competently trained" as it stands for the 110 hour EMT-B.



Let me add to it.

Explain how in Basic class you learn an abbreviated physical exam and history taking and make a determination on whether or not it is serious without understanding of anatomy,physiology, pathophysiology, histology, and biochemistry?

How could you claim such people were "competently trained?" 

Have you ever seen a 70 y/o PE patient scream at you they couldn't breath and fight off 6 firemen? All that stuff about patient airways and chest rise and fall goes right out the window.

In truth I see the need for tiered systems. But until education standards are raised, currently an assessment by a paramedic with some of the background knowledge at a college level is better than the oversimplified version of what is presented in "Emergency Care."

To answer my own question that I posed for debate, ALS is knowledge, not skills or procedures.


----------



## boingo (Feb 14, 2009)

True, the BLS (ALS too) training is inadequate, but at the end of the day, neither group has much to offer to the PE patient.  Unless we are making the dx and giving a thrombolytic, recognizing the problem, notifying the recieving facility and a rapid, safe ride are all that we have to offer.


----------



## VentMedic (Feb 14, 2009)

boingo said:


> True, the BLS (ALS too) training is inadequate, but at the end of the day, neither group has much to offer to the PE patient. Unless we are making the dx and giving a thrombolytic, recognizing the problem, notifying the recieving facility and a rapid, safe ride are all that we have to offer.


 
A little education could keep someone from dxing a PE as just "hyperventilation" and putting the patient's face in a paper bag.  Unfortunately that still happens or the 2 L by NRBM.

So is there even a point to fighting for higher education standards in EMS?

Do many medic mills actually have the right idea as do the FDs (not all) who believe in training and the amount of education as it stands is adequate?

Should we just stop wasting our breath and typing fingers for the education issue? 

Should we just focus on the few skills present in EMS now without looking at what could be?

Should we just make the lowest level provider the standard of care or revert to the scoop and run treatment? 

EMS has managed to survive somehow for over 40 years at the same level with all the other professions have grown. Maybe it is just meant for EMS to stay at a tech level with the votech style of training.


----------



## Ridryder911 (Feb 14, 2009)

I am seeing the "shaking" of those that are fearing the wrath of having to consider to be accredited. Rumors and rumors of rumors, are occurring. Even the thought of removing from the NREMT and attempting to offset the costs of developing test that would costs hundreds of thousands of dollars instead of placing that money into education and doing things right. Yeah, real thinking there. Again EMS is always full of excuses.

I am not going to give up... I do see a light at the end of tunnel. As the shortage has now became at dangerous levels, if medics proceed to do things right we could advance the profession. Yes, there is going to be opposition. Unfortunately, most of this will come within the profession (EMT's) itself.

In regards to Basic EMT, it is just a little more than first aid. Nothing more. The curriculum is not written well enough to be able to screen nor treat injuries or illnesses more than first aid level. Reviewing the new curriculum, it might be a little better but not much. Again most forget it is nothing more than an entry level. This is similar comparison to a nurse aide to a RN. The good thing is that majority of nurses aide realizes and knows their place within the profession realizing they have little to no medical training. 

Is the EMT level warranted? Yes, as a first responder level or for non-emergency transports only. 

R/r 911


----------



## triemal04 (Feb 14, 2009)

VentMedic said:


> Honestly!
> 
> 
> You are a supposedly a Paramedic who should be just as capable of explaining this also.
> ...


You're correct, I am. But I am not one of the paramedic's or ex-paramedic's that was asked to explain it, or, replied to the person who asked that without explaining.  You are.  Instead of, as I said, explaining why knee pn could be indicative of something more serious than say, a torn meniscus, and thus helping someone with less knowledge understand why they should not be so quick to see something as common as knee pn as benign, you choose to go on and on about how medicine is not clear cut (it's absolutely not, I agree completely) and how a basic can't be expected to understand it's complexities.  Basically, instead of using what could have been a teachable moment to it's full advantage, you got on your soapbox.  Cheers.  And don't worry, I'll stay out of this thread from now on.  It's pointless.  Just like last time...and the time before...and the time before...and the time before that.

Veneficus-  thank you.  That's what I was hoping for.  At least now a basic with their minimal education/training will have a better idea of WHY so many people don't blow of the minor complaints.


----------



## triemal04 (Feb 14, 2009)

medic417 said:


> Veneficus did list a number of the possible problems that could be indicated by what many a BLS provider would dismiss and sadly so would many diploma mill paramedics.
> 
> If BLS only responded nothing really could be provided to help those that rapidly crash.  If ALS responded many possible interventions could be started that might get the patient to the hospital with a chance of leaving the hospital alive and basically intact.


DVT, Gullian-Barre sydrome, localized tissue ischemia, osteomalasia, sickle cell crisis, and typhus.  Please list out the treatements that will be done by a paramedic vs a basic and how they will benefit the pt.  Again, this thread get's repeated time and time again, for once let's make it so people can actually learn something from it.  So please, give the treatements so that basic providers will know WHY people are saying that all pt's deserve an ALS assessment.

I swear I'm done now.


----------



## boingo (Feb 14, 2009)

Vent, I agree that educated providers are needed, and hopefully we will see a minimum of an associates required to work in an ambulance.  I'm just saying that the care available really doesn't differ for this particular patient.  Recognizing the problem, initiating basic care and transport is what we have to offer.  As long as the fire service has their hand in EMS in this country education standards will continue to be piss poor.  I am all in favor of change, and do what I can locally to affect this.


----------



## medic417 (Feb 14, 2009)

triemal04 said:


> DVT, Gullian-Barre sydrome, localized tissue ischemia, osteomalasia, sickle cell crisis, and typhus.  Please list out the treatements that will be done by a paramedic vs a basic and how they will benefit the pt.  Again, this thread get's repeated time and time again, for once let's make it so people can actually learn something from it.  So please, give the treatements so that basic providers will know WHY people are saying that all pt's deserve an ALS assessment.
> 
> I swear I'm done now.



First we can do more for them.  Some it as I already stated will just make sure they make it to the hospital.  W/o getting extremely specific I can get 
O2, IV's, go into the drugs if cardiac tons of choices depending on rhythm etc, can go steroidal such as solumedrol, depending on distance thrombolytic, RSI if I need to take control of air way to keep them alive, anxiety and pain management.  Do you get the picture?

Really after a complete ALS exam that started with knee pain I may have to use any number of my nearly 100 drug choices.  A basic can give O2 and the dreaded and should be outlawed "deisel bolus", if they figure out its not just a wasted call.  If it was my family which option would I want?  I want someone that can do something besides drive.  Plus because of the treatment the ride will be smoother and safer for my family member.  So win win by having ALS respond all calls.


----------



## medic417 (Feb 14, 2009)

boingo said:


> I'm just saying that the care available really doesn't differ for this particular patient.  Recognizing the problem, initiating basic care and transport is what we have to offer.



UMMM no we can do much more see my previous post I touched just on a few options.


----------



## ffemt8978 (Feb 14, 2009)

medic417 said:


> UMMM no we can do much more see my previous post I touched just on a few options.



So what do you do for these illnesses that a basic can't, since they were the ones listed earlier in this thread...



> DVT, Gullian-Barre sydrome, localized tissue ischemia, osteomalasia, sickle cell crisis, and typhus


----------



## Veneficus (Feb 14, 2009)

triemal04 said:


> DVT, Gullian-Barre sydrome, localized tissue ischemia, osteomalasia, sickle cell crisis, and typhus.  Please list out the treatements that will be done by a paramedic vs a basic and how they will benefit the pt.  Again, this thread get's repeated time and time again, for once let's make it so people can actually learn something from it.  So please, give the treatements so that basic providers will know WHY people are saying that all pt's deserve an ALS assessment.
> 
> I swear I'm done now.



First off, as vent pointed out, suspicion of a serious injury is the most important part.

But let’s look at some of the things you asked about:

DVT: BLS response: agitation somebody called without a “true emergency” talked into a refusal and left on scene. Perhaps a walk to the ambulance which dislodges the clot into systemic circulation? Maybe a scoop and run to the hospital where the report to the charge nurse gets the patient sent out to triage because of a “possible torn meniscus.”

ALS: suspicion of DVT in the Popliteal vein, cardiac monitor, ongoing assessment for acute ischemia in organs such as heart and brain. Transport to a facility with interventional radiology or vascular surgery. Transfer of care with a report that indicates a closer more urgent need of the patient.

Gullian- Barre as well as typhus: BLS: SAA

ALS: recognition of possible serious condition that could lead to paralysis or death if left untreated.

Sickle cell: BLS: O2 ride to hospital

ALS: O2, IV/NS or ½ normal saline which is the first line treatment to try to reduce clotting and restore perfusion.

Osteomalacia: BLS: no idea what they would make of this

ALS: realization that lack of bone density is systemic and most elderly people suffering from this are at extreme risk for a femoral neck fx. (which in persons over 65 carries a 80% mortality per year) In children can lead to life-long deformity requiring surgery.

Sepsis: BLS: O2, ride to hospital

ALS: fluid replacement as well as vasopressors.

Acute tonsillitis: BLS: Cpap

ALS: ET tube, NT tube, surgical cric. Steroids, mag sulfate

Meningitis: BLS: risk of misDx as flu

ALS: suspicion, transport, report.

That should be enough right now to demonstrate the point. If in the future you recognize the differences, please list them as part of your post.


----------



## medic417 (Feb 14, 2009)

ffemt8978 said:


> So what do you do for these illnesses that a basic can't, since they were the ones listed earlier in this thread...



W/o going deep one key thing is pain relief.  Perhaps more for some of them. Pain relief alone for someone suffering is more than enough justification for ALS response.  

Am I going to break down each possible illness that could be related to the knee pain and the multiple possible treatments?  No.   If someone wants the education they will benefit much more by doing some research rather than relying on us handing them the answers.

Well Veneficus is much nicer than me I see.


----------



## ffemt8978 (Feb 14, 2009)

Thank you, vene....

It's about time people got away from the "I can do more than you realize", and started posting what they would actually or can do.  At least if they want to make this an educational thread instead of an argument based upon the "mine is bigger" mentality.


----------



## medic417 (Feb 14, 2009)

ffemt8978 said:


> Thank you, vene....
> 
> It's about time people got away from the "I can do more than you realize", and started posting what they would actually or can do.  At least if they want to make this an educational thread instead of an argument based upon the "mine is bigger" mentality.




But it gets tiring presenting facts and giving them all the material to back it up and then being called Paragods.  I have given basic reasons that clearly showed the benefit but w/o wasting my time and energy going in detail just to have the information ignored.  Several posts earlier myself and Vent answered that question but w/o giving them everything as then we would be know it all jerks.  This has nothing to do with the "mine is bigger mentallity"  this has to do with people ignoring information provided them.  But now we are the bad guys.  Forget it.


----------



## triemal04 (Feb 14, 2009)

Veneficus-  thank you.  And that wasn't even that hard was it?  And can you guess how much more effective that will be in clueing a basic into why pt's need an ALS assessment rather than simple saying (for all intents and purposes) "because I said so."  (I know not everyone has, and you really haven't, but look at some of the responces so far)

This thread get's repeated probably almost on a monthly basis, and almost all the replies in this one are no different than in any other.  If anybody here has ever had to be a teacher/instructor, then you probably figured out a long time ago that giving real, actual examples is very effective in getting someone to understand something, and, depending on the topic and/or person who's being taught, is MUCH more effective than only giving the theory behind it.  I mean, here I was thinking that part of the reason for this website was so that people could learn...silly me.  

I also think it's rather interesting that only 2 people so far (1 of whom I think is a basic) have pointed out that the most important thing that can be done for some problems is simple recognition and transport to the appropriate facility.

Edit:  medic417, sorry, that's a copout and you know it.  Or should.  You haven't done the things you say, at best all you have done is say that people deserve an ALS assessment because they could have problem X.  For the average basic, that will mean squat.  Explaining what problem X is, how it's recognized by a paramedic and then treated, and what will happen if it's not is infinetely more effective.  If you aren't willing to do that, you may as well cut and paste someones replies from the last incarnation of this thread because they say the same things as here, and will be just as (in)effective.


----------



## medic417 (Feb 14, 2009)

triemal04 said:


> I also think it's rather interesting that only 2 people so far (1 of whom I think is a basic) have pointed out that the most important thing that can be done for some problems is simple recognition and transport to the appropriate facility.



Really a properly educated Paramedic should be able to start many things prior to getting a patient to definitive care besides just transport.  Yes we may not be able to fix everything we should be able to much started so patient starts recovery that much sooner.  If you have so few meds and procedures you really need to start talking to your medical director to improve the guidelines you work under.


----------



## ffemt8978 (Feb 14, 2009)

medic417 said:


> But it gets tiring presenting facts and giving them all the material to back it up and then being called Paragods.  I have given basic reasons that clearly showed the benefit but w/o wasting my time and energy going in detail just to have the information ignored.  Several posts earlier myself and Vent answered that question but w/o giving them everything as then we would be know it all jerks.  This has nothing to do with the "mine is bigger mentallity"  this has to do with people ignoring information provided them.  But now we are the bad guys.  Forget it.



"It gets tiring presenting facts and giving them all the material to back it up..." but it doesn't get tiring thumping your chest and saying "I can do more than you?"  

I looked over this thread carefully, but I may have missed where you stated how you would treat these patients...I saw a lot of ALS is needed because it could be any of these things, but nothing that detailed what would have been done even in general terms.

Like triemal said, a lot of people come here (and to EMS forums in general) to learn.  How much are they really going to learn if all they hear is Basics are worthless, Basics don't know anything, Go to medic school, and I know more than you?

So let's change that, okay?  I issue an open challenge to all members of this forum.  Let's stop thumping our chests and start teaching/educating.


----------



## triemal04 (Feb 14, 2009)

medic417 said:


> Really a properly educated Paramedic should be able to start many things prior to getting a patient to definitive care besides just transport.  Yes we may not be able to fix everything we should be able to much started so patient starts recovery that much sooner.  If you have so few meds and procedures you really need to start talking to your medical director to improve the guidelines you work under.


Really?  Like what?  Let's take the case of a pt with Guillian-Barre Syndrome.  Their only presenting symptom is some weakness to the lower extremities.  No other problems.  And no changes during transport.  Beyond recognition, what magical treatement will YOU do?


----------



## Ridryder911 (Feb 14, 2009)

Should we start basing upon what one can do? If this is the case, the basic level would be banned. Seriously, why not just teach first aid be done with it? 

Even in that perspective, most treatment for those illnesses and injuries are not aggressively treated in the ER. So do they need to bypass that since they do not treat it as well? Other than maybe analgesics, NSAID, and splinting most torn ligament tears are treated per orthoscopy and orthopedic specialities. 

I agree, after reading that many of the Paramedic programs lack educating medics properly but NOT all is that way. As Paramedics do get more education there is more emphasis is being placed upon clinical differential that having the ability to performed as a triage specialist. As more and more hospitals now become more specialized, triaging the patient to the *most appropriate * hospital. As now many may have Stroke Centers, Specialized Cardiac Centers that provide 24 STEMI alert and hypothermic treatment, Spinal Cord facilities, etc. Even in my rural state, there is new rules and regulations that will be based upon the Paramedics assessment, which hospital will receive the patient (similar to trauma). These assessments cannot be interpreted fully at the basic level. 

Not upon so much what treatment that will be performed but what the clinical impression (diagnosis) is. Again, EMS is getting upon so much what we do, rather upon our knowledge and clinical skills. Alike many others it should be based upon.." what I know, rather just the skills I can perform"....

Unfortunately, it will not be EMS that will cause these changes. It will be done by financial instutions and the needs of the increasing over crowding of ER's. Increasing numbers of the baby boomer generation where there will be no beds for ER visits and admissions as well. 

I have been attending State and Federal meeting looking at the future of EMS. I believe many are cutting it short. As economic problems increase, there will have to be alternative ways for medicine. Again, hospitals will NOT be able to accommodate just because of one thinks or desires. Alike many assume they will be automatically admitted, when in fact it admission are a rarity for several reasons. I have been reviewing some states advanced Paramedic proposals as I foresee more home health type evaluation(s) and treatments. Yes, education will have to meet those demands, but that will come along with the program.


R/r 911


----------



## Summit (Feb 14, 2009)

medic417 said:


> DVT, Gullian-Barre sydrome, localized tissue ischemia, osteomalasia, sickle cell crisis, and typhus



While I generally agree with your points if not how you present them, triemal's point was that ALS would not deal that differently with DVT or GBS that much differently than BLS. Rickets? C'mon? You going to push Vitamin D in the field? 

Cardiac, as with a host of other problems, is a different story, but is disingenuous to put out typhus *presenting with knee pain* as a scenario where ALS will "make the difference in quality of life." You aren't going to diagnose typhus in the field based on knee pain. An MD with access to a lab will do that. You won't give antibiotics either.

All of the examples you gave, if the C/C is knee pain, are going to be dealt with by ALS the same as BLS. Sickle cell crisis might be the only exception.

Don't pull out uncommon syndromes because you assume a Basic won't know enough to tell you what I just said here. Use good examples like cardiac. That is the core of honest debate in this subject. If your contention is ALS is the standard because they might be able to give the ED a better report that might lead them down a different path, well you can make that argument. If you want to make the argument that anyone who dials 911 could be having an MI, make that argument.


----------



## medic417 (Feb 14, 2009)

Summit said:


> While I generally agree with your points if not how you present them, triemal's point was that ALS would not deal that differently with DVT or GBS that much differently than BLS. Rickets? C'mon? You going to push Vitamin D in the field?
> 
> Cardiac, as with a host of other problems, is a different story, but is disingenuous to put out typhus presenting with knee pain as a scenario where ALS will "make the difference."
> 
> All of the Zebra examples you gave, if the CC is knee pain, are going to be *treated *by ALS the same as BLS. Transport, no? Don't pull out uncommon syndromes because you assume a Basic won't know enough to tell you what I just said here. Use good examples. That is the core of honest debate in this subject.



I did not post those "zebras"  someone else did.  I qouted that poster.

But I do maintain that any provider at Paramedic level can do more for their patient than just transport.  Perhaps it will only be getting the IV, blood draw, and initial 12 lead.  Perhaps it will be a vitamin injection.  Perhaps it will be pain relief.  Perhaps if someone with one of these non emergent chronic problems they may just need something to help them cope with the anxiety so I can do that with one of my anti-anxiety meds.  My treatments may only band aid but at least gives them some benfit instead of laying there suffering.  Our actions can speed the rate that they get definitive care and make a recovery.

Actually it has been discussed having Paramedics provide antibiotics.  Some services actually do provide them already as well as a few other drugs to get patients started on road to recovery and have them follow up with their doctor on next business day to continue treatment.


----------



## Summit (Feb 14, 2009)

medic417 said:


> I did not post those "zebras"  someone else did.  I qouted that poster.
> 
> But I do maintain that any provider at Paramedic level can do more for their patient than just transport.  Perhaps it will only be getting the IV, blood draw, and initial 12 lead.  Perhaps it will be a vitamin injection.  Perhaps it will be pain relief.  Perhaps if someone with one of these non emergent chronic problems they may just need something to help them cope with the anxiety so I can do that with one of my anti-anxiety meds.  My treatments may only band aid but at least gives them some benfit instead of laying there suffering.  Our actions can speed the rate that they get definitive care and make a recovery.



This seems like a valid argument to me.

BLS who are taught only to think in terms of sick/not sick as meaning dying/not dying might not see that quality of care argument as clearly.

And sorry for the confusion about the stripes.


----------



## ffemt8978 (Feb 14, 2009)

Summit said:


> This seems like a valid argument to me.
> 
> BLS who are taught only to think in terms of sick/not sick as meaning dying/not dying might not see that quality of care argument as clearly.
> 
> And sorry for the confusion about the stripes.



I agree, but my challenge still remains...


----------



## Summit (Feb 14, 2009)

ffemt8978 said:


> I agree, but my challenge still remains...



I think your challenge is a good one. 
I'm a basic. I'm not useless. I'm here to learn and to advocate.
I think you make a point that in the course of advocating the furthering of education and the increasing of standards, and in the course of clarifying our failings as a profession, we needn't purely beat down those we wish to raise up (unless they resist, then beat them with heavy spikey things).


----------



## medic417 (Feb 14, 2009)

ffemt8978 said:


> I agree, but my challenge still remains...




"challenge" My post that summit qouted was educational not chest thumping what more would you like?  I presented ways that we could treat and benfit the patient that is what it is about giving the patients the best.  As a medical professional I refuse to settle to be a means of transportation.  If a patient needs to be in the ambulance care will be started which can and will save time in the chain of medical care.  Anyone that thinks just transportation is proper medical care needs to find a new profession.


----------



## ffemt8978 (Feb 14, 2009)

medic417 said:


> "challenge" My post that summit qouted was educational not chest thumping what more would you like?  I presented ways that we could treat and benfit the patient that is what it is about giving the patients the best.  As a medical professional I refuse to settle to be a means of transportation.  If a patient needs to be in the ambulance care will be started which can and will save time in the chain of medical care.  Anyone that thinks just transportation is proper medical care needs to find a new profession.



I never said it wasn't...my challenge is to everyone on this forum for any future topics, and not just isolated to this thread.


----------



## Summit (Feb 14, 2009)

medic417 said:


> Anyone that thinks *just transportation is proper medical care* needs to find a new profession.



But first we have to get those "in charge" of the profession to stop thinking that.


----------



## triemal04 (Feb 14, 2009)

medic 417-  
While you did not post any of the problems that were listed, you did bring up that knee pn could be indicative of a serious problem.  (and then not explain, but that's another issue).  Now that it has been explained for everyone to see, I honestly would like to hear your opinion on some things.  Do you really consider starting an IV something that would start a pt recovering that much sooner?  (yes, there are times when having a line in place on arrival at the ER is great and beneficial, but the simple presence of an IV, which can generally be obtained in well under a minute will not usually affect a pt's outcome.  Especially in a pt that doesn't really need to be at an ER)  The same can be said for a 12lead and blood draws; they absolutely have their place, don't get me wrong, but often times they have no effect on what happens to the pt.  

Simply saying that we can do certain things without thinking about if those things really matter is almost as bad as saying that all pt's don't deserve an ALS assessment (yes, for the record, for as I'm concerned all do).  Seriously, take someone with GBS as I posted last...what will you do for them, beyond recognition and prep for potential problems that will benefit them?  There are many, many, many pt's that need care that is well beyond what a paramedic can do, and sometimes there is nothing we can do that is helpful to them, other than recognition of their problem, and knowledge about it.


----------



## Veneficus (Feb 14, 2009)

triemal04 said:


> Really?  Like what?  Let's take the case of a pt with Guillian-Barre Syndrome.  Their only presenting symptom is some weakness to the lower extremities.  No other problems.  And no changes during transport.  Beyond recognition, what magical treatement will YOU do?



OK, enough of the picking on people.

GB has some outlandish symptoms. The last pt I saw with it c/c was "falling down." Sometime in medic class (at least us non medic mill instructors) do teach some physio and patho physio, so when these outlandish symptoms appear medics are not at a loss for ideas. Often my students complain about me giving them too much in class. 

The knowledge that this stuff is out there and "could be" what the patient has makes a big difference in pt advocacy. Especially when giving a report to the hospital. It causes providers to overtriage rather than undertriage. (ie err on the side of caution) The glimpse of how much there is to know breaks the "I passed class with a 100% and I know it all" mentality. 

Everyone talks about how a good basic can assess for these things as well as a good medic. I call BS. Theorhetical knowledge must be used in conjunction with physical exam techniques in order to be effective. You have to know what is "normal" just as well as what is grossly abnormal. the higher your medical education the more detailed the history you look for. 

For brevity allow me to cite one example: When was your last oral intake? What was it? How often do you eat? What do you eat? Do you defecate regularly? What is the consistency? The color? Has it changed? Rapid weight loss or gain?

that is way more information than the "L" in SAMPLE.

Used with your knowledge of nutrition, physiology, and patho phys,along with the signs and symptoms presented gives you a very accurate picture of what the problems could be or it may just create a pool of pertinant negatives. It may give you a clue to multiple pathologies, or one aggrivating another. 

How many providers think that a CHF patient's only health problem is CHF? we talked about this on the furosimide thread.

The treatment you give is determined by many things, among them your protocols. I worked on a truck a few years ago that had ~ 50 meds in my bag of tricks and untold pieces of equipment. But sometimes, with the blessing of med command, something had to be made up. Without theorhetical knowledge, that cannot be done. It makes a provider less capable, a hard fact of life. I was once the FR who thought I knew as much as a basic, then I went to medic school, it was an eye opener. The more I learn, the smaller amount of total knowledge I seem to have. 

As us old guys are obligated to teach, the younger ones are obligated to learn. It makes for more constructive conversation at any level when you come with a question rather than a demand.


----------



## medic417 (Feb 14, 2009)

Summit said:


> But first we have to get those "in charge" of the profession to stop thinking that.




Talk to those in charge.  You would be surprised at how receptive many medical directors are if approached with an educated proposal of changes.  Don't walk in and say I want this skill.  Sat we see XXX number of patient that could benefit from this procedure.  Myselef and others at my level have recieved the education to perform.  We would propose that we need to add this drug and this equipment to perform it properly.  We would also welcome you providing us with additional information on it and then a test prior to implementation.


----------



## triemal04 (Feb 14, 2009)

Veneficus-
I'm pretty sure I asked this once before...why are you in Europe again?  Why aren't you back here in the US?  For the love of god man, get your butt back here and jump into fixing EMS with both feet!  The sooner the better!

What you were saying is what I was trying to get across in my last few posts albiet maybe a bit poorly; recognition of a potential problem and knowledge about that problem are huge; the neccasary treatements may be beyond what we can do, but knowing about them is still appropriate.  There are things that we won't have an effect on, unless we have that effect by going to the right hospital and then mentioning to a doc during our passdown that what's going on could be DVT, or GBS, or leukemia etc etc etc, so that the idea is planted in their heads early.  Recognition of a problem is the most important thing we do; and it's done better at some levels than others.


----------



## Veneficus (Feb 14, 2009)

Summit said:


> While I generally agree with your points if not how you present them, triemal's point was that ALS would not deal that differently with DVT or GBS that much differently than BLS. Rickets? C'mon? You going to push Vitamin D in the field? .



The point of the example was not for the treatment, it was to recognize that there may be a more severe health concern than the pain or an orthopaedic insult. Hopefully any medic who passed the A&P requirement understands the lower limb is designed to support the body's weight. Based on this required part of medic education, which is not part of basic education, the medic should realize the problem may not be located in the knee. 

As I have stated many times on many threads, more knowledge = better provider for the patient. Why take my word for it? Ask all the other providers also. 

As for Rickets, it is a reemerging health problem around the world. It does have long term and serious health effects, and can mean the end of life for the elderly. Just look at the instance of hip fx from bone remodeling and the poor prognosis it is associated with. A provider with more education is likely to see a problem where a lesser educated provider doesn't. A vitmin D shot is not the only treatment, it is long term with physical therapy, and other disciplines. But recognizing it and bringing to attention can improve the quality of life for a patient or prevent death from a secondary injury. 

Certaily no healthcare provider advocates not addressing all of a patients health problems? EMS is uniquely positioned to intercede prior to an emergency. (like a broken hip) this idea of sick/not sick, BLS/ALS, needs to go. The days of EMS only being for emergencies are over.


----------



## Shishkabob (Feb 14, 2009)

Lets just solve all the problems with EMS, be done with this "better then thou because I have a different letter after EMT" attitude, and just make Doctors be the one and only care available.


I mean, honestly, those of you who want basics gone state reasons such as education.  Who better then someone that has over 10 times more then a medic?


"But Basics miss might a totally obscure problem that medics won't, but can't do anything about either."

Whats to say the doctor or nurse at the ED, with more education then medics, won't miss it either?  Or catch that which you missed?


----------



## medic417 (Feb 14, 2009)

Linuss said:


> Lets just solve all the problems with EMS, be done with this "better then thou because I have a different letter after EMT" attitude, and just make Doctors be the one and only care available.
> 
> 
> I mean, honestly, those of you who want basics gone state reasons such as education.  Who better then someone that has over 10 times more then a medic?




Lets do it.  I would prefer a doctor taking care of my family.  But that is not attainable.  A Paramedic, heck 2 Paramedics on every ambulance is attainable.  Yes it will take some time.  Education standards for Paramedics will increase and the scope of practice will increase.  Those that choose to ignore the writing on the wall will be left behind and be out of a job.


----------



## Shishkabob (Feb 14, 2009)

I get your point of view, I honestly do.  And it's not a bad idea.  But some of you need to realize the fact that it won't happen ANY time soon, and also realize that until it does, you have no right, rhyme, or reason to disrespect ANYONE because their certificate says Basic instead of Paramedic.


----------



## emtfarva (Feb 14, 2009)

Ok, How about we change education level for all levels.

Basics go through a two year course with 1 year clinical the standard of care will be paramedic level.
paramedics go through a 4 year course on top of basic with a 2 year clinical, thier level of care will be closer to PA or NP level.
will that slove things. then every Pt will get an Als assesment.
oh, wait, we can't do that, Medicare doesn't pay enough. nevermind.


----------



## Veneficus (Feb 14, 2009)

emtfarva said:


> Ok, How about we change education level for all levels.
> 
> Basics go through a two year course with 1 year clinical the standard of care will be paramedic level.
> paramedics go through a 4 year course on top of basic with a 2 year clinical, thier level of care will be closer to PA or NP level.
> ...



no need to worry about medicare, pretty soon it won't be paying for much at all


----------



## medic417 (Feb 14, 2009)

Linuss said:


> Not attainable?  Hmm, doesn't that just shoot your whole argument in the foot  altogether about getting dual medics on EVERY truck in the ENTIRE country?
> 
> What about Anytown USA in the middle of Nebraska, who can not even afford 1 medic?  Your plan isn't attainable there, no matter how hard you push.
> 
> ...



I do not disrespect.  I do ask that you realize how limited as group basics are as I as a medic realize I am.

I will not debate you on the any town as I have already told several ways any community could go ALS paid on previous topics.  

And no my arguement on doctors on ambulances does not blow a hole in my opinion.

I do think the changes are coming within less than 10 years, hopefully much sooner.  I have already seen many services, including some very poor areas with less than 200 calls ayear,  go to at least one Paramedic and several go dual Paramedic.
For reimbursement it is just a matter of time before Medicare/Medicaid/Insurance require it.  

Change is happening now and it is about to get a head of steam.  Get on board or get out of the way.


----------



## imurphy (Feb 14, 2009)

Ok. I've been reading this, and seriously, the EMT-B bashing! Why!

Everyone has to start somewhere. It's when people don't do anything above their B after a few years, that's who you have to worry about. 

Personally, I did my first EMT in 2005 (US-NR). But, since I'm from Ireland, we don't have such an evolved EMS system. We only got "paramedics" in 2008. And they were EMT's untill they were just renamed with *no extra training or scope of practice.* 

So, honestly, realise how good you have it here with a good system, which can of course improve. Personally I will be goign on to get my medic as soon as time and money allows, but it may take a year or so to get to that point. And honestly, I hope when I come out the other side I'm not a bitter "Basics-Know-Nothing" type paramedic!


----------



## medic417 (Feb 14, 2009)

imurphy said:


> Ok. I've been reading this, and seriously, the EMT-B bashing! Why!




Bashing there has been no bashing.  There have some get their feelings hurt by honest answers, but no bashing.

Considering the distance you might consider an online program such as the following to continue your education.

www.techproservices.net


www.percomonline.com


----------



## imurphy (Feb 14, 2009)

No distance problem now that I've moved here. Now it's just saving the money to afford it!


----------



## medic417 (Feb 14, 2009)

imurphy said:


> No distance problem now that I've moved here. Now it's just saving the money to afford it!



I see.  Hope you find the money soon.


----------



## imurphy (Feb 14, 2009)

Tell me about it!! Probably by next year unless I win the lottery!


----------



## medic417 (Feb 14, 2009)

imurphy said:


> Tell me about it!! Probably by next year unless I win the lottery!



See playing lottery is why you have no money.


----------



## ffemt8978 (Feb 14, 2009)

medic417 said:


> Bashing there has been no bashing.  There have some get their feelings hurt by honest answers, but no bashing.
> 
> Considering the distance you might consider an online program such as the following to continue your education.
> 
> ...



Hmmm...the Education Advocate is endorsing on-line programs for the learning of EMS.

:wacko:


----------



## medic417 (Feb 14, 2009)

ffemt8978 said:


> Hmmm...the Education Advocate is endorsing on-line programs for learning of EMS.
> 
> :wacko:




Actually I thought he was in another land and would be unable to go to a college.  

But actually online for the book part is no differenet than any university anymore.  Many universitys allow almost entire degrees online.  

You still attend in person classes for skills and testing.  I noticed when pulling them up that Percom is actually tied to a college program.  

In Texas there are also some online Paramedic programs at universitys but they require multiple classes on campus each month along with the online part.  

Also many online classes require more personal research which helps a person retain more as the more effort to take in and the more senses used in taking in knowledge the more you retain.  

So yes I advocate education and there is quality online education.


----------



## RESQ_5_1 (Feb 15, 2009)

Well, I'm considered BLS here in Canada. But, here are a few of the interventions I'm allowed by protocol and training:

Chest Pain: IV, O2, ASA, Nitro, ECG.

Aaphylaxis: O2, IV, Epi (after OLMC), Bronchiodilators.

Breathing Problems: Auscultation of lung sounds, Bronchiodilators, O2.

Pain Management: Unfortunately, only Entonox.

Regardless, I have gone to a call for PE. And, I have transported pts with suspected DVT. I have been educated to recognize these, and to treat appropriately. Our PE call actually came over from dispatch as a fall (since that's what the pt did before coding in front of us). However, other than interpreting 12 leads (which I can obtain and have actually been trained to read), there aren't very many more interventions or assessments that paramdics can do that I can't.


----------



## CAOX3 (Feb 15, 2009)

Veneficus said:


> First off, as vent pointed out, suspicion of a serious injury is the most important part.
> 
> But let’s look at some of the things you asked about:
> 
> ...



Wow this discussion has exploded.  Healthy debate is good.

I would like to address some of you complaints here. 

A full ALS workup for a party with DVT?  Interesting. 

Guillain Barre is untreatable and I doubt you carry immunoglobulin.  Typhus I am not eve going to dignify that with an answer.

Sickle cell,  No, Unless difficulty breathing is present, signs of possible CVA.  Thats a small percentage.

Osteomalacia, good one.  Because recognition in the field has saved millions of lives worldwide.

Ill give you late stage sepsis but thats a stretch.

Acute tonsillitis, intubated with a surgical airway in the field, I would enjoy reading the data that brought you to this conclusion and the frequency in which this is the prefered tx.

Meningitis,  AlS suspicion, can you charge for that?  Would you just do a spinal tap or a cat scan on the way to the hopital.

It all depends on the presentation of the pt.  Its called ASSESSMENT.

All your examples could warrent an ALS intervention, I am not arguing that.

I am just questioning the frequency in which they do.


----------



## Ridryder911 (Feb 15, 2009)

In question to ALS intervention; anytime that I need to or every time the patient requires intervention. 

For example, sickle cell patients complain of multiple problems usually joint pain, general malaise, fever, etc.. With obtaining history I will start infusing fluids and analgesia. Ruling out Guillain- Barre is difficult as noted but I have had to intubate such a patient in the prehospital setting. The same as differentiating Bell's Palsy vs. a CVA; ( check cranial nerve 7; lesion of CN VII which occurs at or beyond the stylomastoid foramen is commonly referred to as a Bell's Palsy) This matters as if the patient needs immediate transport to a Stroke Center or routine transport to a local ER. 

Again emphasis should be upon building, requiring and demanding better patient assessment. I am now beginning to enforce the "you did not check or know that?" attitude. People will respond if asked or better yet demanded to. Peer pressure can be a good thing when used appropriately. 

Ironically, patient assesment is one of the few things in medicine that requires little to very little additional equipment other than brain power. So let us start demanding nothing more than an adequate assessment. Much of the techniques can be narrowed down and adapted for the prehospital setting. 

R/r 911


----------



## VentMedic (Feb 15, 2009)

There seems to be a limited understanding of ALS, Myasthenia Gravis and Gullian Barre here. All these diseases can progress slowly or very rapidly. And, they can also have immediate respiratory crisis during the long term as well as profound hypo or hypertension. The anxiety level that also comes with one of these crisis must controlled to effectively ventilate these patients.

Similar emergent situations can occur with someone who has para or quadraplegia.

Meningitis: Hypotension, initiate a sepsis resuscitation with fluids and/or meds. 

Sickle cell crisis: pain, fluids, airway management especially with presentation of an acute chest syndrome that may accompany and occasionally does with children or at least.

But what about the other things ALS provides?

Treatment for hypo and hypertension through meds

RESQ_5_1


> However, other than interpreting 12 leads (which I can obtain and have actually been trained to read), there aren't very many more interventions or assessments that paramdics can do that I can't.


Treatment for symptomatic bradycardia through meds and/or pacing before the patient codes.

Give adenosine for rapid SVT.

Treat VT before the code.

Stabilize BP in the MI or other cardiac event.

Treat a cardiac arrest with more than just CPR and the ability to maintain perfusion once ROSC is achieved as well as initiating hypothermia protocols.

Decompress a chest with a life threatening tension pneumothorax.

Treat seizures.
What can BLS do for the child seizing his/her quality of life away?

If one does not understand the potential of an effective ALS system, then chances are you do not have a good ALS system or too limited education to recognize what your ALS system is doing.


----------



## CAOX3 (Feb 15, 2009)

Ridryder911 said:


> Again emphasis should be upon building, requiring and demanding better patient assessment. I am now beginning to enforce the "you did not check or know that?" attitude. People will respond if asked or better yet demanded to. Peer pressure can be a good thing when used appropriately.
> 
> Ironically, patient assesment is one of the few things in medicine that requires little to very little additional equipment other than brain power. So let us start demanding nothing more than an adequate assessment. Much of the techniques can be narrowed down and adapted for the prehospital setting.
> 
> R/r 911



Amen.

Exactley my point, any provider at any level can educate themselves in the practise of pt assessment, its not exclusive to the ALS provider.

Tx is based on assessmnet so if you are not able to assess a pt then the tools you have to treat them become irrelevent.


----------



## medic417 (Feb 15, 2009)

CAOX3 said:


> Amen.
> 
> Exactley my point, any provider at any level can educate themselves in the practise of pt assessment, its not exclusive to the ALS provider.
> 
> Tx is based on assessmnet so if you are not able to assess a pt then the tools you have to treat them become irrelevent.




Your right doctors also assess.   As do many othe medical professionals with education.  The paramedic level provides the minimum amout of education to attempt an assessment.  Any education less than that and patients do not even come close to getting a true medical assessment.


----------



## Veneficus (Feb 15, 2009)

CAOX3 said:


> Wow this discussion has exploded.  Healthy debate is good.
> 
> I would like to address some of you complaints here.
> 
> ...



I just don't think you get it. (or see many patients for that matter) Because BLS assessment is so limited and ALS assessment is less so, an ALS response has a better chance of noticing something is wrong. As Rid, Vent, Medic417 and countless others have said, EMS is no longer viable as a simple ride to the hospital. Recognizing chronic conditions which can cause morbidity and mortality does save lives and function, though maybe not in the glamorous way you desire. If just handling life and death was EMS's goal I could debate the usefulness of EMS in the US at all.

The idea that your value as a provider is measured by what procedures or treatments you can provide is almost laughable. It would be if it didn't cause damage to the EMS profession as a whole. Do you think that MIs are treated in the ED or by cardiology? How about fractures? ED or ortho? Sepsis by the ED or ICU intensivists? Trauma by ED or surgery?  CVA by ED or neuro? By your logic the ED is pretty worthless too. Maybe we could have the outstanding assessment skills of BLS Dx the patients to the appropriate service? Tell me? What texts do basics use to learn their assessment? How much time do they spend on it? How often do they see sick enough patients to distinguish sick from not sick based on disease progression?

If EMS wasn't full of good people trying to advance themselves and they all believed as you do, I think I would give up advocating for them and accept the position of many of my peers and superiors. (Which in a few words is that providers are so undereducated and incapable they are little more than ambulance drivers who should be relegated to just loading the pt in the hearse and driving to the hospital where educated providers can help) Infact after some of the argument here, I think I'll walk in to the hospital tomorrow, admit I was wrong about EMS and argue with equal zeal against EMS. 

I concede your point, ALS does nothing. Congratulations on your victory ambulance driver. I shall seek to make up for my serious lack of judgment regarding the capability and usefulness of EMS by demonstrating how little they know and do and help drive their vocational respect and pay even lower.(because it certanly is no more a profession than any skilled laborer) we could solve the provider shortage really simply, we'll just go down to unemployment round up everyone there, send them through a 110 hour basic course and post them all over the country in a pityful uniform paying them minimum wage w/o benefits.Then we could say we provided adequate healthcare for every town in America by your standards. Why not give them treat and release or refusal of transport capability too? Obviously their assessment is so good from that 110 hour course they are quite capable of deciding when people have a "true" emergency.


----------



## CAOX3 (Feb 15, 2009)

Did I say a provider is measured by the treatment they can perform,I dont think I did,  on the contrary its about recognition not treatment,  without recognition there is no treatment.  End of story.

The Ed is worthless...Hmm did I state that?  Wrong again.

Im not positive but I believe it was Brady Paramedic book.  It was pretty much useless.    

I see about 20 pts in a shift maybe 3 of them are truly sick,  of the rest, maybe 5 actually nedded an ambualance, So that leaves about 12 that didnt even require service. Definitly grounds to staff all ambulances with paramedics.  I see your point.

Then again I am probably wrong, they all needed an ALS intervention.  Thats why the majority of them our discharged before I even finish my F'n paperwork.

So your argument doesnt fly with me.  ALS plays a vital role in EMS, no one knows that better then me.  To state that BLS plays no role, preach it to someone else.


----------



## medic417 (Feb 15, 2009)

CAOX3 said:


> I see about 20 pts in a shift maybe 3 of them are truly sick,  of the rest, maybe 5 actually nedded an ambualance, So that leaves about 12 that didnt even require service. Definitly grounds to staff all ambulances with paramedics.  I see your point.
> 
> Then again I am probably wrong, they all needed an ALS intervention.  Thats why the majority of them our discharged before I even finish my F'n paperwork.



They all deserve an ALS assessment so there is less chance of something being missed.  If after ALS assessment and it is an dual staffed ambulance the basic could take the patient with the Paramedic driving.   Your right not all callers need ALS interventions but they all deserve an ALS exam.  Then they can even be denied transport if they do not have a need for immediate emergency care.


----------



## Sasha (Feb 15, 2009)

CAOX3 said:


> Then again I am probably wrong, they all needed an ALS intervention.  Thats why the majority of them our discharged before I even finish my F'n paperwork.
> .



Jeez louise! Get down off your high BLS horse long enough to read where Rid, Vent, medic417 and Vene are trying to pound into your head that sometimes an advanced assessment is the best thing for that patient, not necessarily ALS intervention. 

Why are you defending having less educated personnel take care of people? This is health care, not cosmetology (which, suprisingly, has more of a training requirement then a Basic EMT class.). How can you be so anti-education?


----------



## ffemt8978 (Feb 15, 2009)

medic417 said:


> They all deserve an ALS assessment so there is less chance of something being missed.  If after ALS assessment and it is an dual staffed ambulance the basic could take the patient with the Paramedic driving.   Your right not all callers need ALS interventions but they all deserve an ALS exam.  Then they can even be denied transport if they do not have a need for immediate emergency care.



Interesting point...

How many times have ALS providers misdiagnosed a patient, only to have it end up on the news later?  How many times have BLS providers misdiagnosed a patient to have it end up on the news later?  

I would like to see if anyone has any studies to back up the statements that ALS providers are less likely to miss something.  I think the results might surprise some of you, but I could be wrong.  While BLS may not know what is exactly wrong with the patient, they are more likely to transport to the hospital for definitive diagnosis (this is based solely off of the lack of news articles about BLS not transporting a patient and having it end up o the news as compared to ALS not transporting a patient and having it end up on the news)


----------



## medic417 (Feb 15, 2009)

Sasha said:


> This is health care, not cosmetology (which, suprisingly, has more of a training requirement then a Basic EMT class.). How can you be so anti-education?



Careful, I think they require more hours than many Paramedic programs.  SHhhhhh!!! don't let that leak out to the basics though they might rebel.h34r:


----------



## medic417 (Feb 15, 2009)

ffemt8978 said:


> Interesting point...
> 
> How many times have ALS providers misdiagnosed a patient, only to have it end up on the news later?  How many times have BLS providers misdiagnosed a patient to have it end up on the news later?
> 
> I would like to see if anyone has any studies to back up the statements that ALS providers are less likely to miss something.  I think the results might surprise some of you, but I could be wrong.  While BLS may not know what is exactly wrong with the patient, they are more likely to transport to the hospital for definitive diagnosis (this is based solely off of the lack of news articles about BLS not transporting a patient and having it end up o the news as compared to ALS not transporting a patient and having it end up on the news)



Actually while I have not seen any actual study on this subject based on news reports both are guilty of poor patient assessments way to often.  I have seen articles listing both.  Also in news reports it is hard to say what level of responder is accussed of what, as some reporters call us all EMS workers, others call us all ambulance drivers, still others call us all EMT's, and yet others call us all Paramedics regardless of actual level.  Also the news only prints the attn grabbers they do not put out information when the EMT or Paramedic is cleared or if they do its back page small notice.  

Based on more medical education common sense should suffice that ALS would be less likely to miss a problem than someone with less education.  Now factor in laziness as there are many check collectors that have no business in EMS at any level.  And as you said BLS pretty much has to transport all that request in most services, so even though they got no medical care and the EMT had no idea what was wrong, patient did get to hospital.  

Another point to consider is the news involved because they died in the ambulance getting the same ACLS treatment the doctor would be attempting on the patient that the BLS crew brought in.  Both die yet news jumps on the Paramedics despite the fact the patient actually had a better survival chance because drugs, etc were started sooner, and despite the fact the current CPR guidelines say not to do rolling CPR.  The basics do not get accused of anything in that the actual death was at hospital even though they were already dead if CPR was being done in the ambulance.  

But I would love to see a real study that actually factors in points such as above.


----------



## VentMedic (Feb 15, 2009)

ffemt8978 said:


> Interesting point...
> 
> How many times have ALS providers misdiagnosed a patient, only to have it end up on the news later? How many times have BLS providers misdiagnosed a patient to have it end up on the news later?
> 
> I would like to see if anyone has any studies to back up the statements that ALS providers are less likely to miss something. I think the results might surprise some of you, but I could be wrong. While BLS may not know what is exactly wrong with the patient, they are more likely to transport to the hospital for definitive diagnosis (this is based solely off of the lack of news articles about BLS not transporting a patient and having it end up o the news as compared to ALS not transporting a patient and having it end up on the news)


 
And with higher levels of licensure comes higher expectations and responsibilites. One may not expect an EMT-B to pick up some things but it may be expected of a Paramedic. Do EMTs and Paramedics actually have the same expectations for identifying various medical conditions with the same accountibility? You can use the example of CNA and RN. Who would be held more accountable? The same expectations are not there so there is no fair way to make that comparison. 

How many times have any licensed providers in healthcare screwed up and it has made news? There ARE many published studies there and a nationwide action has been put into place by increasing everyones' awareness, more education and retraining. How many in EMS review their own policies when they hear of a major incident happening somewhere? Often when I post a news item about an EMS provider accused of inadequate care, it is to learn something from it and not try to judge who's right or wrong. The others in healthcare are already taking notes and learning from mistakes or medical errors. What have those in EMS done? 

So it appears that there are more wanting to be just an ambulance ride to the hospital. Any person working in a hospital at a lower level cert using these same arguments as some on the EMS forums who want only BLS would be laughed out of medicine. But, they would be welcomed in the EMT world. Fortunately healthcare has set its standards higher and EMS is not the role model.


----------



## CAOX3 (Feb 15, 2009)

I say we just put MDs on all ambulances, then we will never have this discussion again.

Then I can retire at 60%.  

Sasha dont assume you know my educational background. 

By the way when uneducated people teach its training.

When educated people teach its education.

The majority of EMs proffesionals are trained not educated.

When that changes maybe I will consider it, I doubt I will see it in my lifetime though.

I enjoy more traditional education, and I having taken full advantage of my tuition reimbursment.

This is fun.


----------



## emtfarva (Feb 15, 2009)

An als assement might be good, but I know a place where they can get an even better assement then any paramedic can give. And just to let you know, most of the AMI that my partner and I have transfered to a stemi center came by their own vehicle. And those weird knee pn MI's also came to the hosp by own vehicle.


----------



## Sasha (Feb 15, 2009)

emtfarva said:


> An als assement might be good, but I know a place where they can get an even better assement then any paramedic can give. And just to let you know, most of the AMI that my partner and I have transfered to a stemi center came by their own vehicle. And those weird knee pn MI's also came to the hosp by own vehicle.



You speak for only the small percentage of such patients that you see. Not everyone else.

Of course, a better assesment will be done at the hospital. But what if an EMT talks that knee pain into a refusal because they think it's a "BS, drug seeking call"? When will that knee pain GET to the hospital?

Why are you content to just drive the ambulance and not provide patient care?


----------



## VentMedic (Feb 15, 2009)

CAOX3 said:


> I say we just put MDs on all ambulances, then we will never have this discussion again.


 
Been there and done that already.  We did have MDs on several 911 ALS trucks during the 70s and 80s as well as on the specialty teams such as Flight and CCT.   However, with a lot of hard work it was demonstrated that Paramedics could perform advanced skills and assessments. 

Now you want to set us back to that time and undo the work those before you have done?  That would also include Rid and myself since we were part of that earlier generation of Paramedics who were taught that there was a future for EMS.


----------



## Veneficus (Feb 15, 2009)

The point I was trying to make clear was the more theoretical knowledge(aka formal education) you have about the sciences of health and disease the more likely you are to identify health concerns. Not just acute emergences, but overall health. 

From the practical side, yes, some medics over estimate the knowledge they have. Some also accidentally equate experience or training as education. 
All providers miss findings. I have seen more than my fair share of medics who are not thorough or skillful in their Dx. But from the point of the basic, because of the skills based approach, a Dx may not even be possible for them to make. Not for lack of effort or desire, from lack of formal knowledge. It is nothing to be ashamed about. We are all part of the team and have different functions. I have posted several times my defense of the basic level providers as well as the need for them. But the more education you have, the more likely you are to notice problems.

I would guess that many basics don’t misdiagnose, because they are not diagnosing. They are assessing whether or not there is a life threatening condition relating to airway, breathing or circulation. These are not the only life threatening conditions. Some will affect the patient sooner than others.  Some conditions may become life threatening if left untreated, which is the hazard in statements like “12 didn’t require service.” If no other interventions they may have required the service of a physical exam & history, risk stratification and disposition. 

On other threads it has been argued that all patients should get a ride to the hospital. I will not revisit that argument except to point out that healthcare in the US must change. We no longer have the money to pay to continue doing things how we have been. Part of that reform will require lessening the amount of patients seen in the ED by caring for minor problems or problems that can wait in the field. The only field providers available without an already documented established need for a visiting nurse or physician is EMS.
Ems constantly pays lip service to prevention. Indisputably the best healthcare is that which prevents illness. Second to that is preventing illness from progressing. For its own sake EMS must accept this change in role, but it is also the greatest benefit to the patient. 

A basic who walks into an ED with a patient and says “I don’t know what is wrong” is better for a patient than a basic who says “don’t worry it is nothing” and that is what touched off the argument. But in the next 10 years basics may not have the option to transport everyone to the ED.


----------



## emtbill (Feb 15, 2009)

Can anyone recommend a good text to read that might expand our knowledge of the signs and symptoms (and what we can do about them) of medical conditions less commonly taught in most paramedic programs?


----------



## medic417 (Feb 15, 2009)

emtbill said:


> Can anyone recommend a good text to read that might expand our knowledge of the signs and symptoms (and what we can do about them) of medical conditions less commonly taught in most paramedic programs?



First review the major Paramedic Texts such as Mosby, Brady, and AAOS. Each one provides information that the others miss.   Also a search of the web sites from those texts will find many other texts that may prove beneficial.   Another help is look over the ER docs shoulder and see what reference he/she is looking into.  Or ask him/her.


----------



## Veneficus (Feb 15, 2009)

emtbill said:


> Can anyone recommend a good text to read that might expand our knowledge of the signs and symptoms (and what we can do about them) of medical conditions less commonly taught in most paramedic programs?



Robins and Coltran pathologic basis of disease

Harrison's textbook of internal medicine

Sabiston textbook of surgery


----------



## daedalus (Feb 15, 2009)

Veneficus said:


> Robins and Coltran pathologic basis of disease
> 
> Harrison's textbook of internal medicine
> 
> Sabiston textbook of surgery



add: DeGowins Diagnostic Examination.

(not directed at anyone)Oh, and by the way, as a current basic, I will say strongly that Basics cannot and do not diagnose or even create a list of potential diagnosis. We simply do not have the knowledge to do that. A high school student's guess is as good as a Basic's most of the time. This is something I struggle with. I pick up patients and do the assessment required of me and I want so badly to say "oh! this is definitely pneumonia!" But I cannot. It frustrates me.


----------



## emtbill (Feb 15, 2009)

How about something that's not 1000 pages?


----------



## reaper (Feb 15, 2009)

emtbill said:


> How about something that's not 1000 pages?



2000 be better?


----------



## Sasha (Feb 15, 2009)

emtbill said:


> How about something that's not 1000 pages?



I'm currently reading a pharmacology text book to try and teach myself. 

If you really want a good understanding of a subject you're not going to get it out of a short "Pharmacology for dummies" book or one chapter out of a paramedic book. It's gonna be lengthy because there's so much to know and understand but in the end you will be better for it.


----------



## EMTinNEPA (Feb 16, 2009)

*Blah blah blah*



medic417 said:


> UMMM what to say and how to say it.  That is stupid.  Sorry but knee pain can be indicative of many things and warrants an ALS response.  As to the ill person almost ever code I have worked was dispatched as an ill person but I guess they did not deserve an ACLS attempt to save their lives per your system.  :wacko:



If every code you've ever worked went out as an "ill person", maybe the flaw lies with your dispatch system.  Try not throwing stones unless you know your own house is perfect.



medic417 said:


> Sorry every patient deserves an ALS exam.   And again in reality ALS should be the minimum of patient care on every ambulance.  Even the stubbed toe call could be masking some other real problem that at the basic level would be missed.  I have had more than one patient thats only sign/symptom with BLS exam was big toe pain that turned out to be having an acute MI.



Yes, and I have a history of depression.  Therefore, if I decided to abuse the system and call 911 for transport to the hospital, even if I denied any other signs of symptoms, I should tie up one of the four (on a good day) ALS trucks in the entire county because there is a slight chance that my depression is an abnormal presentation of a giant pink rhinoceros who poops rainbow-flavored marshmallows about to fly out of my nose, which would compromise my airway and result in, well... my death.  Since there isn't a person on that truck with those nine magic letters on their shoulder, any ride on a BLS truck would be an automatic death sentence, eh?  Well, I guess I should just forget about the four jobs I work as an EMT and just go back to medic school.  Then once I graduate, I should refuse to work anywhere that doesn't staff two medics since I'd be doing my patients an injustice.



medic417 said:


> Now if your service chooses not to have the best which would be two Paramedics per ambulance but runs an Basic/Paramedic ambulance then after an ALS exam care could be given by the basic allowing the Paramedic to drive.  But an ALS exam is warranted on all calls.



It's not about what my service choses to do, it's about available resources.  Since there is currently a medic shortage in my area and half the full-timers at every service I've ever worked for have been EMTs who are full-time simply because they've been there since the days of Johnny and Roy and have been too lazy to move up, the Good Ole Boys system and the "We've Always Done It This Way" Ideaology is keeping ANY progress from being made.

And I know this because I was actually FIRED from what used to be my main department for daring to criticize the current system.

Quit wasting time blabbering about how things SHOULD be and, oh, I dunno, try to do something so it actually HAPPENS.  But only if you're one of the Good Ole Boys since us "newbies" aren't allowed to know anything, be any good at our jobs, or have any opinions.


----------



## EMTinNEPA (Feb 16, 2009)

And what in the blue hell has gotten into everybody on this forum the past few days?  I'm sick and tired of sitting here watching Basics try to justify their existence to paramedics and paramedics or medic students being offended and setting up strawman arguments like "Oh, I guess ALS is useless".  It's freaking ridiculous.  This is exactly what is wrong with EMS.  Everybody is out to discredit or belittle everybody else.  For Christ's sake, Basics and Medics are supposed to WORK TOGETHER.  Basics... PARAMEDICS KNOW MORE THAN YOU.  Paramedics... YOU WERE ALL EMT-Bs ONCE, DON'T FORGET WHERE YOU CAME FROM.

So, until one of you stops complaining and actually does something to...

A. increase the level of education for an EMT-Basic
B. magically give the world more paramedics, or
C. Both

...please, for the love of all that is holy, do me a favor...

SHUT UP, STOP WHINING, AND GET A LIFE!!


----------



## Meursault (Feb 16, 2009)

Gods, parts of this thread are awful. medic417, you sound like you took Rid's old posts and completely excised the sense of humor and proportion.  Everybody who's dragging out the BLS/ALS dead horse for another round of flogging, search for some of the old threads and reflect carefully on whether you actually have anything to contribute to the discussion.
For everybody else: Weren't we talking about the criteria for requesting an ALS intercept or simultaneously dispatching ALS about... 13 pages ago?


----------



## ffemt8978 (Feb 16, 2009)

And that's enough of this one.


----------

