# National EMS Scope of Practice Model Revision



## EpiEMS (Mar 21, 2017)

Has anybody raised questions or comments to the NAEMSO with respect to the National EMS Scope of Practice Model revisions?

Anything you'd like to suggest? Here's the current version.

Naturally, EMR and EMT naloxone is something they're talking about. I'm thinking about mentioning:

Additions for EMRs:
 - Tourniquets
 - Nasal airways
 - Assist with patient prescribed auto-injector for anaphylaxis

Additions for EMTs:
 - Glucometry
 - CPAP for EMT
 - Field cervical spine clearance at the EMT level
 - Epinephrine autoinjectors for anaphylaxis and severe asthma exacerbations

Additions for AEMTs:
 - ETCO2 for AEMTs (if you're placing Esophageal-Tracheal Multi-Lumen Airways, shouldn't you be placing ETCO2?)

Not so sure about medics...

Removal/material alteration suggestions:

I think they should alter lines like: "The Emergency Medical Technician may make destination decisions in collaboration with medical oversight." to say "The Emergency Medical Technician may make destination decisions in collaboration with pre-established protocols and/or on-line medical oversight."


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## VentMonkey (Mar 21, 2017)

EpiEMS said:


> Anything you'd like to suggest?


Yes, paramedics:

A more focused approach to a respiratory module, and perhaps basic ventilator management, or a properly, and appropriately  suited introduction.

Otherwise, remove intubation altogether; we really need to stop fooling ourselves.


EpiEMS said:


> if you're placing Esophageal-Tracheal Multi-Lumen Airways, shouldn't you be placing ETCO2?


Yes, absolutely.


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## hometownmedic5 (Mar 21, 2017)

Sometimes I forget that there are place in this country more backwards than MA. Everything on that list with the exception of CPAP is already in our BLS scope and i consider them fundamentals. Envisioning a system where that's not the case cooks my noodle...


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## NomadicMedic (Mar 21, 2017)

As they always say, if you've seen one EMS system, you've seen one EMS system. 

As someone who's worked in multiple states, first as a basic, then as a medic, there is NOTHING the same about any of them, with the exception that they all call themselves EMS. 

My suggestion is a TRUE national scope of practice for paramedics and to stop trying to patch up shaky systems with piecemeal certs. 

It's should be EMT and PARAMEDIC. That's it. 
EMT should double the length of the program and focus less on the lifesaving and more on the hand holding and customer service. An EVOC module should be mandatory. 

Paramedic should be a mandatory 2 year program with much more focus on the patho and less on the hero. And yes, intubation should probably be pulled. None of us are competent.


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## Carlos Danger (Mar 21, 2017)

I didn't realize this was up for review again. I'll have to review the old one and give it some thought.

@EpiEMS I think your suggestions are all good ones. @VentMonkey and @NomadicMedic, I personally probably wouldn't advocate removing intubation at this point. De-emphasize it for sure, and I don't think RSI should be a standard intervention,  but I do think intubation is something that paramedics should get some exposure to and practice with during their initial training.


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## hometownmedic5 (Mar 21, 2017)

I agree. We either need to way increase initial training, coupled with mandatory recertification and performance requirements, or scrap it all together. What we have now is a crap shoot. Some providers are good at it just because they've done it a million times. Most of us are terrible(mainly due to lack of opportunities and minimal understanding). 

I could live in world where all I had was an SGA.


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## VentMonkey (Mar 21, 2017)

Remi said:


> I personally probably wouldn't advocate removing intubation at this point. De-emphasize it for sure, and I don't think RSI should be a standard intervention,  but I do think intubation is something that paramedics should get some exposure to and practice with during their initial training.


Remi, I'd love for you to elaborate, and I'm not being a smartarse here either.

How do we de-emphasize, yet still remain proficient? Do you think that's a reality? Should it only be left for certain (specialty certificate) providers? 

Also, where--if at all--do you think RSI fits into prehospital medicine?


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## SpecialK (Mar 21, 2017)

EpiEMS said:


> Additions for EMTs:
> - Glucometry
> - CPAP for EMT
> - Field cervical spine clearance at the EMT level
> - Epinephrine autoinjectors for anaphylaxis and severe asthma exacerbations



What about the following?

Entonox or methoxyflurane (I can't believe you guys don't have either of these!)
GTN 
12 lead ECG acquisition
Salbutamol and ipratropium
IM midazolam for status epilepticus 
IM adrenaline (from a syringe - why bother with a bloody autoinjector?)
IM and IN naloxone (you blokes probably use it a bunch)
IM glucagon (if you can take a BGL why can't you treat hypoglycaemia)
Oral ondansetron

We have some other things like tramadol, olanzapine and loratadine plus something else I am forgetting but they're not "big ticket" items.  I would even say GTN is probably not that important ... no evidence it really does anything good anyway but doesn't seem to be going away any time soon!


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## VentMonkey (Mar 21, 2017)

@SpecialK all great stuff. Only one small snag...'murrica.


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## Jim37F (Mar 22, 2017)

I do wish I had something more than cold packs for pain......give me something more than that and something for nausea and those two alone would make me feel 99% more effective when the ALS squads here inevitably BLS any trauma that's not a Trauma Center activation or any other pain that isn't painful to them to look at lol vs the current method of "I know you're in abdominal pain and I can't do anything for it and even the hospital isn't giving any meds whilst letting you wait on my gurney in the hallway"........(we're more likely to get something like Entonox or methoxyflurane at the BLS level for pain management here than we are to change that culture.....)


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## DesertMedic66 (Mar 22, 2017)

If we are going to give EMTs any of those additional medications there needs to be a lot of education about them on the EMT level.


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## Dennhop (Mar 22, 2017)

On the subject of etco2, may as well move that to an EMT-B level, since EMT-B can place nonvisualized airways, such as king's or combitubes...


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## SpecialK (Mar 22, 2017)

VentMonkey said:


> @SpecialK all great stuff. Only one small snag...'murrica.



So what you are saying is America is not a developed first world nation which wants its ambulance personnel to be able to look after their patients if they are not at Paramedic or ICP equivalent levels ... right.

Well, you're not saying that obviously (I am joking) so ....


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## Carlos Danger (Mar 22, 2017)

VentMonkey said:


> Remi, I'd love for you to elaborate, and I'm not being a smartarse here either.
> 
> How do we de-emphasize, yet still remain proficient? Do you think that's a reality? Should it only be left for certain (specialty certificate) providers?
> 
> Also, where--if at all--do you think RSI fits into prehospital medicine?



I'm not really talking about proficiency, as I don't think most paramedics graduating from most paramedic programs are proficient in the skill anyway. I think it should be de-emphasized both in protocols and training programs. But I still think it should probably be taught. 

Kind of like (<paramedic instructor speaking> "now that we've spent a lot of time on respiratory physiology, mechanical ventilation, mask ventilation, and SGA's, we're going to go over endotracheal intubation. This is something that you probably won't do, at least not until you are further on in your career and go to work for a HEMS program or something along those lines, at which time you'll get a lot more training on it. But it is a skill that every paramedic should have had at least some exposure to". 

I think there are some settings where ETI and RSI makes sense to have in your protocols, but I think it should be reserved for agencies that have more of a need for it, and have relatively small numbers of paramedics, heavy med director involvement in training and QI, and some opportunity for frequent training on it.


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## EpiEMS (Mar 22, 2017)

SpecialK said:


> What about the following?
> 
> Entonox or methoxyflurane (I can't believe you guys don't have either of these!)



'Murica, man - the FDA pulled them, I believe. That said, nitrous is in AEMT scope.



SpecialK said:


> GTN



Administration of patient's own is in EMT scope, and AEMT scope includes SL nitro (GTN).



SpecialK said:


> 12 lead ECG acquisition



That's a good one - and there is a good evidence base for EMS 12-leads speeding door-to-balloon time, though I'm not sure if it extends to those done by (non-interpreting) BLS providers.



SpecialK said:


> Salbutamol and ipratropium



Administering patient's own inhalers is in EMT scope, AEMT includes administration of inhaled beta agonists, not just the patient's own.



SpecialK said:


> IM midazolam for status epilepticus



Not so likely - narcotics raise a whole set of control issues. It's not in AEMT scope. Not sure how much evidence there is that IM midazolam is used frequently enough, anyway?



SpecialK said:


> IM adrenaline (from a syringe - why bother with a bloody autoinjector?)



I totally agree - that being said, people are scared about EMTs doing anything "invasive". This is coming around throughout the country, but I think cost of autoinjectors will fall precipitously soon enough.




SpecialK said:


> IM and IN naloxone (you blokes probably use it a bunch)



Absolutely - I think they're already considering this.


SpecialK said:


> IM glucagon (if you can take a BGL why can't you treat hypoglycaemia)



As with the autoinjector - I'm 100% with ya, this'd be good at the EMT level. It is already in-scope for AEMTs.



SpecialK said:


> Oral ondansetron



Ooh, I like this one. The ability to reduce nausea would be excellent. Not sure about downside risk of Zofran at the EMT level, though. Maybe just give it to AEMTs?


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## hometownmedic5 (Mar 22, 2017)

It is in the New Hampshire bls scope to acquire and transmit 12lds without interpretation. I don't know if any services are actually providing 30k dollar monitors to basics, but on paper it's allowed.


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## hometownmedic5 (Mar 22, 2017)

In a perfect world, aemt would be entry level to staff an ambulance(with most if not all of the above); but we know that will never happen. You don't need to be advanced to do the renal round up or haul nana to the manor, and that's primarily the job description of BLS.


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## EpiEMS (Mar 22, 2017)

hometownmedic5 said:


> It is in the New Hampshire bls scope to acquire and transmit 12lds without interpretation. I don't know if any services are actually providing 30k dollar monitors to basics, but on paper it's allowed.



It's in CT and NY protocols, too - there are options that are cheaper, e.g. the ReadyLink



hometownmedic5 said:


> In a perfect world, aemt would be entry level to staff an ambulance(with most if not all of the above); but we know that will never happen. You don't need to be advanced to do the renal round up or haul nana to the manor, and that's primarily the job description of BLS.



I absolutely agree - but in this world that we have now, EMT is the basic level, so I don't see a problem in upskilling EMTs slightly (and obviously increasing the length of the curriculum commensurately).


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## hometownmedic5 (Mar 22, 2017)

EpiEMS said:


> It's in CT and NY protocols, too - there are options that are cheaper, e.g. the ReadyLink
> 
> 
> 
> I absolutely agree - but in this world that we have now, EMT is the basic level, so I don't see a problem in upskilling EMTs slightly (and obviously increasing the length of the curriculum commensurately).



Adding to the emt training to increase skills, add some knowledge and end up with an expanded scope; but not arriving at the true ALS level. That sure sounds like advanced emt to me. 

Then again, since day one, ems in this country has been about appearances and half measures. We created emt-I as a stepping stone between b and p. Now, you're suggesting a stone between b and I?

What we need is to dump I altogether. Raise bls to ils, keep paramedic, and in a perfect world id love to see ccp as the first step to a college requirement. It would be such a beautifully smooth transition. At first, just the cc medics need a degree(associates). A few years go by, cc becomes a bachelors, medic becomes an associates. Hell, maybe even someday we go one more step and make critical care paramedics mid level providers and maybe finally get a seat at the table. 

Oh what a world that could be...


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## EpiEMS (Mar 22, 2017)

hometownmedic5 said:


> Then again, since day one, ems in this country has been about appearances and half measures. We created emt-I as a stepping stone between b and p. Now, you're suggesting a stone between b and I?



Given that measures like epinephrine autoinjectors, CPAP, and BLS 12 lead acquisition are fairly commonplace (or safe and evidence based practice that ought to be adopted), I'm not seeing the issue with adding it to the scope of practice model. Your concern seems broader, to me, than the SOP model.


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## VentMonkey (Mar 22, 2017)

SpecialK said:


> So what you are saying is America is not a developed first world nation which wants its ambulance personnel to be able to look after their patients if they are not at Paramedic or ICP equivalent levels...


I'm not _not_ saying that.


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## hometownmedic5 (Mar 22, 2017)

So my issue is dog piling skills/procedures onto people without education. I see it as a half measure. 

If you want basics to have an expended scope, let's just make basics intermediates and be done with it. We dont need another half rank or regional speciality certifications (emt-iv; bls intubation with a waiver and so on). If we're going do make a go of this national scope idea, let's stop playing games and get it done.


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## VentMonkey (Mar 22, 2017)

@Remi I believe we share a similar thought process with regard to prehospital ETI.

That's about what I would envision as most practical. In essence you're covering airway management, and once there's a firm grasp of the _entire management process_ from beginning to end, ETI may be taught for what it is...a skill. One that is way overemphasized as it stands now, but the "bigger picture" itself being airway management, is currently all but null and void.

We haven't _earned_ the right to practice this as a group of clinicians, collectively IMO. We haven't even earned the right to call ourselves clinicians, let alone practitioners as a group.

I would think a "skill" like this deserves way more credit, and in turn respect, than we've given it over the past 50 or so years.


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## EpiEMS (Mar 22, 2017)

So time for me to write a nice letter, I guess?

Key takeaways for me that I can find good evidence for: 
 - Tourniquets for everybody (a good-enough summary here, obviously I'll provide links to studies)
 - Epinephrine autoinjectors for EMTs, push assisting down to EMRs, too (because it is the gold standard for anaphylaxis and is not available enough)
 - Glucometry and CPAP for EMTs
 - Cervical spine clearance for all levels (EMT and above)

How about that?
Anything else I'm missing? I know some folks had some suggestions at the Paramedic level....


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## Jdog (Mar 23, 2017)

EpiEMS said:


> So time for me to write a nice letter, I guess?
> 
> Key takeaways for me that I can find good evidence for:
> - Tourniquets for everybody (a good-enough summary here, obviously I'll provide links to studies)
> ...



Honestly, I would love to see oral ondansetron added to the EMT scope. Probably won't happen, but one can only dream.


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## EpiEMS (Mar 23, 2017)

Any major downsides to ODT Zofran (other than, I guess, if you are intractably vomiting, it is probably useless)? (@VentMonkey? @NomadicMedic?)


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## MonkeyArrow (Mar 23, 2017)

EpiEMS said:


> Any major downsides to ODT Zofran (other than, I guess, if you are intractably vomiting, it is probably useless)? (@VentMonkey? @NomadicMedic?)


It got "blackboxed" by the FDA for use in pregnant women.


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## NomadicMedic (Mar 23, 2017)

EpiEMS said:


> Any major downsides to ODT Zofran (other than, I guess, if you are intractably vomiting, it is probably useless)? (@VentMonkey? @NomadicMedic?)



 Works great for nausea, doesn't work very well for someone who is actively vomiting. 

I use the ODT's prophylactically. "Here, please let this dissolve in your mouth. Hold this yak sak and don't puke on me."


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## EpiEMS (Mar 23, 2017)

@NomadicMedic Any major risks to worry about?


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## DesertMedic66 (Mar 23, 2017)

MonkeyArrow said:


> It got "blackboxed" by the FDA for use in pregnant women.


It had a warning label put on it for continued use during pregnancy. Last I checked there were no studies done about single doses. We still give it for pregnant females.


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## NomadicMedic (Mar 23, 2017)

DesertMedic66 said:


> It had a warning label put on it for continued use during pregnancy. Last I checked there were no studies done about single doses. We still give it for pregnant females.



Yep. And it's cautioned in a few other meds. Apomorphine is one. It also may prolong QT. 
The use in pregnancy was off label and I think GSK paid a big fine for promoting the off label uses. 

It's got a few issues, but still very widely used.


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## SandpitMedic (Mar 23, 2017)

Regarding intubation, perhaps intubation itself is not the crux of the issue. Perhaps it is the way most paramedic students are taught to intubate.

First off, it's taught like this glorious end all be all of being a paramedic (according to newbs). It's taught in such a fashion that it is meant to be this 30 second emergency procedure. "YOU HAVE 15 SECONDS TO GET THIS TUBE OR YOU ARE A KILLER!!!" "GET THIS TUBE IN 8 SECONDS OR YOU'LL BE A WEAK PARAMEDIC FOREVER!!!?"--- ummmm... no.
So much emphasis on speed and just getting the tube...

There should be nothing fast about taking someone's airway. It should be smooth and methodically done. You should be fully prepared and ready for alternative ways to achieve the goal. Obviously, this is a time sensitive procedure, but it certainly should not be a rush procedure. First pass success should be the ultimate goal during training; preparing and setting yourself up for success the first time. In addition, I've seen too many times a second attempt the same as the first... if you didn't get it the first time (which is bad) then change something the second time...don't make the same mistake twice. There is also much much more than just "getting the tube" such as how to appropriately manage the patient once the tube is in place...

It should be taught as a smooth non-dramatic procedure. Not this life saving hero move.

And one more thing, if I had to pick one piece of equipment on the Ambulance/Aircraft that is the most underutilized it would be.... the bougie.

Use every tool you have to ensure first pass success, and don't rush it. The training needs to be changed. Also, none of us are heroes.


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## VentMonkey (Mar 23, 2017)

SandpitMedic said:


> Regarding intubation, perhaps intubation itself is not the crux of the issue. Perhaps it is the way most paramedic students are *taught to approach intubation*.
> 
> First off, it's taught like this glorious end all be all of being a paramedic (according to newbs). It's taught in such a fashion that it is meant to be this 30 second emergency procedure. "YOU HAVE 15 SECONDS TO GET THIS TUBE OR YOU ARE A KILLER!!!" "GET THIS TUBE IN 8 SECONDS OR YOU'LL BE A WEAK PARAMEDIC FOREVER!!!?"--- ummmm... no.
> So much emphasis on speed and just getting the tube...
> ...


I honestly didn't think that the whole "you're weak if you can't get the tube" mantra was still a thing with preceptors, and trainers, deplorable. I'm not completely surprised, and yes I agree that there needs to be more focus on how it is performed, but again, clearly we need to wipe the approach as it stands currently altogether.

As you eluded to, it's just "getting the tube", and nothing more. If we approach airway management like we should be approaching much of what we do, from a _preventative_ standpoint, we'll be not only more educated about all of the proper procedures, options, and techniques, but we will have changed our end goal from "I'm awesome because I can put a piece of plastic between a persons vocal cords.", to "it can probably wait until we get to the hospital.", or "I should really be doing this properly to begin with because as my respiratory module indicates there's a higher likelihood of my patients hospital stay lengthening, and/ or them developing pneumonia-->ARDS is way high; maybe I _should_ employ proper aseptic techniques and take my time so that I decrease their length of stay; this would be preventative."

That's what I mean by de-emphasizing. You're absolutely right, we're not heroes. I don't think I have ever seen, or heard a physician tout they're a hero because they had to intubate a patient they were reluctant to (in my experience the better physicians have this approach to clinical airway management). Then again, they possess the knowledge-base to understand the onslaught of susceptibility they've just opened said patient up to. What do we possess that says we should continue to be allowed such a giant responsibility?


NomadicMedic said:


> It also may prolong QT.


This is the one I most commonly hear applicable to us about Zofran, maybe because it involves ECG's? Lol, I don't know. My understanding about the prolongation of QT intervals is that it's more prevalent with extremely high doses (e.g., perhaps what a cancer patient being treated via chemotherapy may be ingesting). It's not to say that it can't happen, but overall it appears to be mostly a benign medication, so yes, ODT Zofran could probably be added, and of benefit to the EMT scope of practice.


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## Carlos Danger (Mar 23, 2017)

@SandpitMedic everything you wrote is 100% correct. Intubation is merely an intervention, and not even a complex one at that. In theory, virtually anyone can learn the skill and acquire the judgement needed to place an ET tube. Still, we still find ways to screw it up. All_the_time. 

Complex or not, it does take time and resources to teach airway management, and more time and resources to maintain it. And the consequences of letting someone loose to do the intervention without having fully developed the skill are dire. When I was in paramedic school in 1997-1998, I remember talking about how we really should get a lot more/better training in airway management than we did. And now, two decade later, we are still having the same exact talk. We all recognize the importance of improving training in airway management, which is why "airway" such a frequent topic of conversation. In spite of that, there has been virtually _zero_ progress in the area of airway training for paramedics for at least as long as I've been involved in EMS. The national curriculum is virtually the same. Paramedics are still graduating their programs with 3 or 4 live intubations (or less). I still pretty frequently see paramedics in the OR who just don't really seem to understand what is going on. The research that is unsupportive of paramedics doing RSI in the field just continues to pile up - a new study came out just a few weeks ago - I think that's the 17th or 18th in the past 20-25 years that says pretty much the same thing as the rest. Can the problem even be fixed? I don't know. Probably. I can't see why not. But whether it's because paramedic programs and EMS agencies _can't_ or _won't_ improve things, it just isn't happening. 

A good argument can also be made that intubation by paramedics in the vast majority of cases simply isn't necessary. CPAP is everywhere now, and SGA's have improved dramatically. Many paramedics intubate less than 5 times a year, and a large majority intubates less than 10 times a year. That's probably not only well below the threshold needed to maintain competency, but it also indicates that maybe it's a skill that they don't even really need. 

Are there exceptions to all the negativity? Of course. Which is why I don't think it should be removed from the paramedic scope of practice across the board.


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## Carlos Danger (Mar 23, 2017)

VentMonkey said:


> This is the one I most commonly hear applicable to us about Zofran, maybe because it involves ECG's? Lol, I don't know. My understanding about the prolongation of QT intervals is that it's more prevalent with extremely high doses (e.g., perhaps what a cancer patient being treated via chemotherapy may be ingesting). It's not to say that it can't happen, but overall it appears to be mostly a benign medication, so yes, ODT Zofran could probably be added, and of benefit to the EMT scope of practice.



Zofran has been proven to prolong the QTI to a greater extent than droperidol did, and droperidol was effectively done away with because of the black box warning that it was slapped with for that purpose around the same time that zofran came out (conspiracy theory, anyone?). It doesn't take a large dose of zofran to prolong the QTI, either.

That said, I don't think there has ever been a case of lethal arrhythmia that was attributed to zofran, even in the really high doses. It's probably about as safe as a drug can be.


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## NomadicMedic (Mar 23, 2017)

Remi said:


> Zofran has been proven to prolong the QTI to a greater extent than droperidol did, and droperidol was effectively done away with because of the black box warning that it was slapped with for that purpose around the same time that zofran came out (conspiracy theory, anyone?). It doesn't take a large dose of zofran to prolong the QTI, either.
> 
> That said, I don't think there has ever been a case of lethal arrhythmia that was attributed to zofran, even in the really high doses. It's probably about as safe as a drug can be.



I was giving zofran to a young woman who was sick and her dad, who was there (and did not offer to drive her to the hospital BTW) was an oncologist. He asked what I was giving her and when I said 8 of zofran said, "is that enough? We give huge doses to chemo patients." 

Our ED docs are like, "woah! You gave 8mg of zofran?" I'm so tired of the dark ages. 

As an aside, my wife took so much Zofran when she was pregnant, we almost considered naming my daughter Zöe Frances, so we could call her ZoFran. True story.


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## VentMonkey (Mar 23, 2017)

"You know you're a paramedic, or EMT when..."


NomadicMedic said:


> As an aside, my wife took so much Zofran when she was pregnant, we almost considered naming my daughter Zöe Frances, so we could call her ZoFran. True story.


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## DesertMedic66 (Mar 23, 2017)

NomadicMedic said:


> I was giving zofran to a young woman who was sick and her dad, who was there (and did not offer to drive her to the hospital BTW) was an oncologist. He asked what I was giving her and when I said 8 of zofran said, "is that enough? We give huge doses to chemo patients."
> 
> Our ED docs are like, "woah! You gave 8mg of zofran?" I'm so tired of the dark ages.
> 
> As an aside, my wife took so much Zofran when she was pregnant, we almost considered naming my daughter Zöe Frances, so we could call her ZoFran. True story.


I named my son Laryngo Scope. You should see all the weird looks I get. Next kid I am going to name Yaunker Non-rebreather


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## SandpitMedic (Mar 23, 2017)

Some schools are churning out new medics with 0 live intubations. zero. I've heard that from multiple folks in education, and here in my area there is a private school that does not require it.

Manikin medicine.

ALS-only fire recruiting has really been a detriment to paramedics and the role of a paramedic. But that's another conversation.


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## VentMonkey (Mar 23, 2017)

SandpitMedic said:


> ALS-only fire recruiting has really been a detriment to paramedics and the role of a paramedic. But that's another conversation.


I would consider this a sub-topic, elaborate?

Is the greater LV area absolutely flooded with paramedics? If so, do you think a system such as this, coupled with presumably short ETA's to the ED, really needs ETI in their protocols?*

*there, it's still sort of on topic.


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## DesertMedic66 (Mar 23, 2017)

SandpitMedic said:


> Some schools are churning out new medics with 0 live intubations. zero. I've heard that from multiple folks in education, yet I don't think in my area it's a thing yet.
> 
> Manikin medicine.
> 
> ALS-only fire recruiting has really been a detriment to paramedics and the role of a paramedic. But that's another conversation.


I believe NCTI and Victor Valley are allowing students to only have manikin tubes


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## SandpitMedic (Mar 23, 2017)

DesertMedic66 said:


> I believe NCTI and Victor Valley are allowing students to only have manikin tubes


True


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## EpiEMS (Mar 23, 2017)

Remi said:


> A good argument can also be made that intubation by paramedics in the vast majority of cases simply isn't necessary. CPAP is everywhere now, and SGA's have improved dramatically. Many paramedics intubate less than 5 times a year, and a large majority intubates less than 10 times a year. That's probably not only well below the threshold needed to maintain competency, but it also indicates that maybe it's a skill that they don't even really need.
> 
> Are there exceptions to all the negativity? Of course. Which is why I don't think it should be removed from the paramedic scope of practice across the board.



Sounds like we need a new level of provider , an "Advanced Paramedic," say??



SandpitMedic said:


> Some schools are churning out new medics with 0 live intubations. zero. I've heard that from multiple folks in education, and here in my area there is a private school that does not require it.



Wow, that's profoundly disturbing. Goes back to my point above, I think.


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## SandpitMedic (Mar 23, 2017)

VentMonkey said:


> I would consider this a sub-topic, elaborate?
> 
> Is the greater LV area absolutely flooded with paramedics? If so, do you think a system such as this, coupled with presumably short ETA's to the ED, really needs ETI in their protocols?*
> 
> *there, it's still sort of on topic.


There are multiple variables. 

The flood of people becoming Paramedics simply to gain a firefighting career is not a new thing. However, I'd venture to say that this has caused for-profit schools to try and make a buck on that. Therefore, churning out Paramedics with the least possible competencies they can possibly get away with. 

No live intubations required to graduate and become a certified paramedic?!
Either the agenda is to pu$h them through a$ fa$t a$ po$$ible, or to help eliminate pre-hospital intubation in the long game.

I don't believe distance from difinitive care has anything to do with securing an airway. If the patient needs a secure airway, you secure the airway. As a competent provider you should be able to make the call, and if required properly prepare, intubate, manage, and transport the patient. SGA's and other means are available, and should be utilized if necessary. 
There are time sensitive emergencies where obviously getting them to the ER quicker is better, but A comes before B comes before C, which you should also be able to do on the road or in flight if required.


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## SandpitMedic (Mar 23, 2017)

EpiEMS said:


> Sounds like we need a new level of provider , an "Advanced Paramedic," say??.


 We do... it's called critical care.


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## EpiEMS (Mar 23, 2017)

SandpitMedic said:


> We do... it's called critical care.



Not part of the National Scope of Practice model - agreed, though, CCP has been is widely adopted as a paramedic plus some skills level.


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## VentMonkey (Mar 23, 2017)

EpiEMS said:


> Sounds like we need a new level of provider , an "Advanced Paramedic," say??


Perhaps even a nationally recognized critical care paramedic (CCP) would be sufficient? Then again, we have enough provider levels as it stands now.

What I took away from most from 6 or so months worth of critical care training was more of what I should, or shouldn't be doing as a "standard" street paramedic, and why. The biggest take away I gained personally was what our instructor liked to tell us, which was:

the biggest difference between a paramedic and a critical care paramedic is their critical _thinking_.

It has so little to do with "cool procedures", and so much more about the when's, where's, and why's they're done, or not. I can certainly see how this may not be everyone's "cup of tea".

Unfortunately, we work in a comparison-driven industry where your story gets trumped by my cooler story, who's then gets trumped by the next persons coolest story. So as usual, how will any of this help us _develop_ and _progress_?


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## SandpitMedic (Mar 23, 2017)

EpiEMS said:


> Not part of the National Scope of Practice model - agreed, though, CCP has been is widely adopted as a paramedic plus some skills level.


I'd say putting in chest tubes could be considered "plus some skills." Lol.

I'd also say it's less about skills and more about the knowledge base. More patho, more pharm, more everything. Not just doing skills, but having a better foundation of knowledge, why we are doing something, the patient's clinical course, and what can we do to improve those factors.

In my opinion, it should be baseline paramedicine.


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## VentMonkey (Mar 23, 2017)

SandpitMedic said:


> In my opinion, it should be baseline paramedicine.


@SandpitMedic you're right, it should be, unfortunately it isn't. And as you've pointed out above, it appears to be going the exact opposite direction in the United States.

As an aside, I don't think chest tubes belong in a non-sterile environment setting (considered a sterile procedure, rightfully so). I think finger thoracotomy's are a sufficient replacement, and needle decompression is still acceptable in most cases.


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## SandpitMedic (Mar 23, 2017)

Right, I was just using that as an example of "plus some skills"
Generally, if the patient warrants a chest tube in the field, their outcome isn't likely to be positive anyhow. That'd likely be a hot mess of a patient to begin with.


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## VentMonkey (Mar 23, 2017)

EpiEMS said:


> CCP has been is widely adopted as a *paramedic plus some skills level*.


As myself and Sandpit eluded to, Ep, I would caution this mental approach to this provider level. 

I'm not saying you're insinuating this (I know you're much brighter than that), I would just hate to see a standard paramedic take this approach only to have the same backlash that Sandpit describes with many profit-driven puppy mills known as "paramedic schools". 

It would thereby defeat the purpose by having that "specialty cert/ provider level". It's actually the reason for the often debated worth behind such specialty certs (FP-C, CCP-C, etc.) now as they stand. 

It's a good reason I personally continue to advocate that newer paramedics get, at minimum, a few years tucked under their belts before they even _think_ about delving into such exams.


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## EpiEMS (Mar 23, 2017)

@VentMonkey, definitely not trying to suggest that CCP is "just more skills" - more that there should be recognition of the specialized (or super-paramedic, if you will) in  the National Scope of Practice model, so we can at least acknowledge that there are specializations (or otherwise) above the "standard" paramedic level.

Of course, it is the knowledge (not so much the skills) that specialty providers bring (as @SandpitMedic alludes to) that is most valuable.


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## VentMonkey (Mar 23, 2017)

Right, but as it stands now we apparently have paramedic programs requiring zero live intubations, and "specialty certs" that a recent grad from one of these programs could take in a heartbeat. 

Clearly, this country has no clue where it's going with its prehospital providers. And also other providers who think this may encourage super-medics, or a pseudo-mid level. 

I don't think that's the case. I can't see any value in an advanced paramedic specialist taking any jobs out of any mid levels hands. 

Perhaps other people who actually think there's no value in extending curriculum don't wish to see this field mature into a profession? I really don't know. 

I can understand the mindset of those who argue we only perform, or are trained to perform a limited amount of skills in a relatively short timeframe. We _were_, however, clearly times have changed and we're no longer solely providing a limited amount of skills. It's clearly not the case anymore, I fail to see how it isn't universally seen, or adopted. 

My personal opinion is that there is just way too much to gain financially from these programs, so what bare minimums? Well, I suffer by watching the next generation of paramedics fumble, and they'll continue to watch the generation afters theirs do the same. And unfortunately a handful of prudent, intelligent, well-intended providers from each generation doesn't seem to be doing enough good for the viability, or sustainability of the profession.


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## EpiEMS (Mar 23, 2017)

VentMonkey said:


> Clearly, this country has no clue where it's going with its prehospital providers.



When I took my initial EMT course, I thought "hey, this is going to be great - there's the NREMT, there's an EMS office in the federal government, there's scope of practice documents!" Little did I know, there is a patchwork of state law, medical director whim, and service...operational issues. It's a real shame from a systems perspective!

From the individual provider level, it's a mess - as you say!


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## VentMonkey (Mar 23, 2017)

EpiEMS said:


> When I took my initial EMT course, I thought "hey, this is going to be great - there's the NREMT, there's an EMS office in the federal government, there's scope of practice documents!" Little did I know, there is a patchwork of state law, medical director whim, and service...operational issues. It's a real shame from a systems perspective!
> 
> From the individual provider level, it's a mess - as you say!


Yep, the trickle down sucks, but where it counts more (legislation) it matters not.


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## EpiEMS (Apr 4, 2017)

Interesting little note: It sounds like EMT use of epinephrine auto-inectors is de-facto national scope. I don't have full access to the journal, but here is a poster from the authors. They note that 17 states require epinephrine on BLS ambulances, and 30 permit it.


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## EpiEMS (May 1, 2017)

Hey all:

NAEMSO is asking for input.

I gave my very circumscribed suggestions:

 Add epinephrine autoinjector administration (EMS stocked) and hemostatics for EMR; add epinephrine, hemostatics, CPAP, and glucometry for EMT; add CPAP for AEMT


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## DrParasite (May 1, 2017)

SandpitMedic said:


> I'd say putting in chest tubes could be considered "plus some skills." Lol.


That's pretty cool.... but how easy or difficult is it to put in a chest tube?  how many times a year is it needed to be done on a live person to maintain competency?  And assuming it's a low use /  high risk skill, that can save someone's life, will it fall into the same group as intubation?

And to be honest, how often are you putting in a chest tube in an IFT, or a CCT, where one is indicated and hasn't already been placed by the sending facility?


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## SandpitMedic (May 2, 2017)

DrParasite said:


> That's pretty cool.... but how easy or difficult is it to put in a chest tube?  how many times a year is it needed to be done on a live person to maintain competency?  And assuming it's a low use /  high risk skill, that can save someone's life, will it fall into the same group as intubation?
> 
> And to be honest, how often are you putting in a chest tube in an IFT, or a CCT, where one is indicated and hasn't already been placed by the sending facility?


 I think just because something is high risk doesn't mean it shouldn't be done. How many chest tubes are going in at ERs? Physicians maintain competency... they're actually fairly simple to do, and there are only a few steps to remember and a few cautions. So long as folks are trained properly and kept proficient by demonstrating on cadavers it's fine.
Adding more skills to the hat serves to progress the profession forward. More importantly, as I said earlier, the knowledge of when to/not perform a skill and why you're doing such is more important than the skill itself. 
Doing a physician and advanced practitioner skills in the field as a paramedic (properly) is a huge leap for EMS, a huge leap forwards.

In my opinion, fire based EMS is the problem with such advancements. While some may say that is not germane to this topic, I assure it all comes back to that. I'm in EMS... 95% of my training has been medical/EMS related for the past 9 years or so. A firefighter/paramedic who has the same time on the job would say that 95% of their training was fire/rescue related and 5% EMS. 

There are other factors that EMS has which need attention, however that is numero uno. 

To the last part of your post, the places we pick up usually end up with us being the highest level of care- not always on paper if you catch my drift. I've seen folks with a lot of letters not know how to do/when to do a 12 lead, withhold epi on anaphylaxis because the patient was tachy, had no idea how to use an IO, insist no blood was needed for an open book pelvic fracture, etc etc.... If anyone is going to be doing a chest tube, it will most likely be me and my partner in my response area regardless of it's a scene or IFT. 

Generally it happens once a year, however quarterly you are required to demonstrate the skill, as well as surgical and needle crics.

I'm a fan of advancing EMS. I am not making an attempt at hubris or trying to be tacticool, I simply think that we can be trained and we can be competent. We can begin the same treatments in the field that they will recieve at a difinitive care facility. It doesn't have to stop at the mega code, we could use the same strategy for septic patients, some traumas, breathers, etc.


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## rescue1 (May 4, 2017)

SandpitMedic said:


> Adding more skills to the hat serves to progress the profession forward. More importantly, as I said earlier, the knowledge of when to/not perform a skill and why you're doing such is more important than the skill itself.
> Doing a physician and advanced practitioner skills in the field as a paramedic (properly) is a huge leap for EMS, a huge leap forwards.



While I agree with most of what you said, I've never been a huge fan of the "keep adding more skills" plan for improving EMS. I would argue that most American paramedics don't even have the pharm/physio/pathophys education for the skills that they currently perform (those medic mills at the top of the page being good examples). So while I agree that doing advanced skills properly is a huge leap forward, I would argue that its a better leap forward if we can have the education to make the best use of our current skillset. Perhaps I'm more cynical than you about paramedic education in the US though. A part of my brain says that if we keep adding skills, we'll end up with paramedics operating at the level of a PA/NP, but with an associates degree instead of 6 years of education. 

As a second point, I think that simply beginning definitive treatment in the field is not always as cut and dry as it appears. Therapeutic hypothermia is relatively effective when performed in a hospital, and ineffective when performed in an ambulance. This makes me suspicious of prehospital antibiotic administration for sepsis, for example. Not because I think paramedics can't give antibiotics, but because I find that we're very quick to jump on cool new things before we really know how effective it is.

I don't say these things to crap on EMS or to suggest that the scope of practice should be limited, just that I think we take things slowly, with the exception of increased education, which I think should be our #1 (or at least very high) priority. 


Also these thoughts don't apply as much to critical care/HEMS stuff. I've worked in rural (I'm guessing) areas like you described in your post and am aware of the inexperience that a lot of the physicians there have with critical patients. I have minimal experience with CC transports, so I'd be talking out of my *** there anyway.


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## SandpitMedic (May 4, 2017)

rescue1 said:


> While I agree with most of what you said, I've never been a huge fan of the "keep adding more skills" plan for improving EMS. I would argue that most American paramedics don't even have the pharm/physio/pathophys education for the skills that they currently perform (those medic mills at the top of the page being good examples). So while I agree that doing advanced skills properly is a huge leap forward, I would argue that its a better leap forward if we can have the education to make the best use of our current skillset. Perhaps I'm more cynical than you about paramedic education in the US though. A part of my brain says that if we keep adding skills, we'll end up with paramedics operating at the level of a PA/NP, but with an associates degree instead of 6 years of education.
> 
> As a second point, I think that simply beginning definitive treatment in the field is not always as cut and dry as it appears. Therapeutic hypothermia is relatively effective when performed in a hospital, and ineffective when performed in an ambulance. This makes me suspicious of prehospital antibiotic administration for sepsis, for example. Not because I think paramedics can't give antibiotics, but because I find that we're very quick to jump on cool new things before we really know how effective it is.
> 
> ...


That's a lot.
I'll respond in time when I've had time.


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## VFlutter (May 4, 2017)

VentMonkey said:


> It would thereby defeat the purpose by having that "specialty cert/ provider level". It's actually the reason for the often debated worth behind such specialty certs (FP-C, CCP-C, etc.) now as they stand.
> 
> It's a good reason I personally continue to advocate that newer paramedics get, at minimum, a few years tucked under their belts before they even _think_ about delving into such exams.



I agree. I feel the same about most nursing certifications, except CCRN. A true critical care certification should require vetted experience in a critical care environment. If not, it doesn't hold much value in my opinion. 

Taking a one year provider and pushing them through a critical care certification course does not create a critical care provider.


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## Carlos Danger (May 4, 2017)

rescue1 said:


> While I agree with most of what you said, I've never been a huge fan of the "keep adding more skills" plan for improving EMS. *I would argue that most American paramedics don't even have the pharm/physio/pathophys education for the skills that they currently perform *(those medic mills at the top of the page being good examples). So while I agree that doing advanced skills properly is a huge leap forward, I would argue that its a better leap forward if we can have the education to make the best use of our current skillset. Perhaps I'm more cynical than you about paramedic education in the US though. A part of my brain says that if we keep adding skills, we'll end up with paramedics operating at the level of a PA/NP, but with an associates degree instead of 6 years of education.



I agree 100%. Especially with the part that I bolded.

Is placing a chest tube - for example - a fairly simple skill? Yeah, if you do them a lot. But what if you don't? I'm not sure annual practice on a manikin or even a cadaver really qualifies one to perform a critical skill. Crics are an exception because they are truly a do-or-die situation. I think that's exactly why the referring docs in these "band aid station ED" scenarios that we always talk about often don't have everything done that we see done in a higher level receiving facility. I think these docs know their limits and can admit that they aren't really experts in resuscitation and understand that discretion is the better part of valor. Paramedics are often not as good at such se

What does this mean for paramedics performing these types of advanced skills? Well, if they are truly trained and current on the skill, then by all means go for it. But I think that's where this whole thing falls apart. If even a _physician_ staffing an ED can admit that they aren't competent to do something, I think it's a stretch to imagine that a paramedic with a fraction of the the training is competent to do the same skill. Again, this doesn't apply to a paramedic who truly _is_ adequately credentialed in a given procedure, but I think that once you start looking, you'll see that the type of preparation that EMS deems "adequate training" for a given skill is very often well below the level of education that every other advanced clinician has to demonstrate in order to be credentialed to do the same procedure.

I also happen to be of the opinion that a rigorous education in anatomy, physiology, and pathophysiology should be considered a pre-req to training in surgical procedures. Again, only EMS argues against that.


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## SandpitMedic (May 5, 2017)

rescue1 said:


> While I agree with most of what you said, I've never been a huge fan of the "keep adding more skills" plan for improving EMS. I would argue that most American paramedics don't even have the pharm/physio/pathophys education for the skills that they currently perform (those medic mills at the top of the page being good examples). So while I agree that doing advanced skills properly is a huge leap forward, I would argue that its a better leap forward if we can have the education to make the best use of our current skillset. Perhaps I'm more cynical than you about paramedic education in the US though. A part of my brain says that if we keep adding skills, we'll end up with paramedics operating at the level of a PA/NP, but with an associates degree instead of 6 years of education.
> 
> As a second point, I think that simply beginning definitive treatment in the field is not always as cut and dry as it appears. Therapeutic hypothermia is relatively effective when performed in a hospital, and ineffective when performed in an ambulance. This makes me suspicious of prehospital antibiotic administration for sepsis, for example. Not because I think paramedics can't give antibiotics, but because I find that we're very quick to jump on cool new things before we really know how effective it is.
> 
> ...


I agree with most of what you said, and also agree wholeheartedly with @Remi 

I would only argue you point about PAs/NPs in  that a PA/NP is not that much farther than a Critical Care Paramedic with years of high volume experience in an _*emergency* setting_. Don't jump me just yet for saying that.
I'm not saying that CC medics need a new level of cert or are the same as a PA, nor am I intending to diminish the level of education and profession of advanced practice providers.

My wife is a APRN, and I am friends with many PAs and APRNs. I'm on the PA track myself. That said... you can have a bachelor's degree in liberal arts, biology, or basket weaving, et. al., and wake up one day (having zero medical experience) and go to PA school. Likewise, you can get into an accelerated program from ASN to BSN straight to MSN without any time providing patient care... Boom, now you have providers with zero experience in emergency medicine other than a 3-6 week ER rotation. 

Advanced practitioners are primarily trained in family medicine during their graduate studies. Very few specialize in emergency medicine, and furthermore the typical tract includes only one year of didactic training in, again, family/general medicine. That is followed up with one year of clinical rotations; the rest is OTJ training and specialized training. 

So why can't baseline for a paramedic degree be at least a year of A&P, basic biology, microbiology, and chemistry? 

I've been a proponent of raising the bar on EMS education for some time. I'm topped out save for a BS in EMS (which is of little use). I have all my certs, an associate's degree, FP-C, and most science prerequisites for PA/med school. My best training has been that which I have elected to pursue including critical care and general ed. 

Nothing I've learned in virology or general chemistry I or II has helped me in treating a septic patient or a thoracic trauma patient.... just saying. 

Practicing medicine with a biology degree and a masters in physician assistant is cool and all, but in our specific field I feel that we could take the same prerequisite coursework and be better for it. Again, I am not knocking PAs, I'm just saying their training in family medicine has zero implications during resuscitation or other emergent critically ill patients. I'd love to be a PA or MD/DO. They are well trained and competent providers in their given specialty and family practice. 

Do not misunderstand me; my argument is not against them, rather it is for EMS. EMS needs higher education standards in formal education as well as clinical training. Current standards of most paramedic didactic training flat out sucks. There is barely any A&P, pathology, or human biology involved. This can be mitigated by adding coursework, elimination of non-accredited private schools (medic mills), and increasing responsibilities. In doing that we will create better clinicians and better opportunities for our profession. It would promote growth, longevity, and professionalism in EMS.


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## Carlos Danger (May 5, 2017)

SandpitMedic said:


> My wife is a APRN, and I am friends with many PAs and APRNs. I'm on the PA track myself. That said... you can have a bachelor's degree in liberal arts, biology, or basket weaving, et. al., and wake up one day (having zero medical experience) and go to PA school. Likewise, you can get into an accelerated program from ASN to BSN straight to MSN without any time providing patient care... Boom, now you have providers with zero experience in emergency medicine other than a 3-6 week ER rotation.
> 
> Except these people by and large aren't working in EM or critical care. They are doing primary care or the non-acute care roles. If they do end up in a critical care role, they'll have substantial additional training and probably not manage sick patients independently for a long time, if ever.
> 
> ...


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## SandpitMedic (May 6, 2017)

Sure, you're on to something. I did state in comparison to an emergency setting regarding rescue1's comment about a 6 year educated PA, so no argument- I think we are saying the same things. 

Higher education does build on itself. Regardless, formal education should be an integral part of becoming a paramedic as it is for other medical professions, yet still a critical care provider it does not make.  

I think we are approaching the same conclusion with different ways of reaching it.


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## rescue1 (May 6, 2017)

Yeah I think we're all basically saying similar things. I wasn't trying to suggest that a freshly minted midlevel provider should be expected to bounce from school directly into an emergency or critical care environment with minimal supervision the way we expect a paramedic to. 

All medicine is primarily taught "on the job", from physicians in residency to EMT clinicals and everything in between. My only point, which we're probably all in agreement on, is that without a firm grasp of the science behind it, there's only so much you can learn, regardless of how much experience you have.


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## EpiEMS (Aug 3, 2017)

Hi all -- looks like the NAEMSO has a new document (front matter, mostly) for comment.

The committee is identifying "5 key areas as priority topics: 
1. Use of opioid antagonists at the BLS level 
2. Therapeutic hypothermia following cardiac arrest 
3. Pharmacological pain management following an acute traumatic event 
4. Hemorrhage control 
5. Use of CPAP/BiPAP at the EMT level"


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## taxidriver (Aug 10, 2017)

Sorry for reviving this post but I have some insight that I'd like to add. There are states that simply need basics that have a wider scope of practice. I work for a private ems company that works all the 911 calls for a whole city ( don't want to specify which.) nevertheless, it's a poor city and EMS is very active. The city does not have a fire department and it does not have a police department. The county sheriff covers it for law enforcement, a nearby city for fire, and our company covers the medical side of things. When ALS is busy with the "I feel sick" and "I stubbed my toe" calls and a real emergency comes up, what then? We have to fix this on a state by state if not county by county level. Yes, basics here have CPAP, combit/king, IM epi for anaphylaxis and severe respiratory diatesss. But we should be trained to deal with some more complex cardiac emergencies, establish IV access even if only for a small number of drugs, and overall give us the ability to run more calls by ourselves. So many calls that get dispatched with ALS end up being transported with no ALS interventions it makes me cringe. Make the class longer and give us more to work with. Once the 911 system has more confidence in basics and let us run certain calls by ourselves the system will be a lot more efficient.


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## luke_31 (Aug 10, 2017)

taxidriver said:


> Sorry for reviving this post but I have some insight that I'd like to add. There are states that simply need basics that have a wider scope of practice. I work for a private ems company that works all the 911 calls for a whole city ( don't want to specify which.) nevertheless, it's a poor city and EMS is very active. The city does not have a fire department and it does not have a police department. The county sheriff covers it for law enforcement, a nearby city for fire, and our company covers the medical side of things. When ALS is busy with the "I feel sick" and "I stubbed my toe" calls and a real emergency comes up, what then? We have to fix this on a state by state if not county by county level. Yes, basics here have CPAP, combit/king, IM epi for anaphylaxis and severe respiratory diatesss. But we should be trained to deal with some more complex cardiac emergencies, establish IV access even if only for a small number of drugs, and overall give us the ability to run more calls by ourselves. So many calls that get dispatched with ALS end up being transported with no ALS interventions it makes me cringe. Make the class longer and give us more to work with. Once the 911 system has more confidence in basics and let us run certain calls by ourselves the system will be a lot more efficient.


It's called a tiered dispatch that's what you're looking for. If they have a problem with having enough ALS ambulances, the solution isn't increase the scope of a EMT, it's hire more paramedics or only use advanced EMTs. The scope of practice you are talking about is covered by advanced EMTs.


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## Summit (Aug 10, 2017)

EpiEMS said:


> Hi all -- looks like the NAEMSO has a new document (front matter, mostly) for comment.
> 
> The committee is identifying "5 key areas as priority topics:
> 1. Use of opioid antagonists at the BLS level
> ...



Prehospital therapeutic hypothermia has not been proven effective and we'll see how long the hypothermia component remains vs TTM.


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## taxidriver (Aug 10, 2017)

luke_31 said:


> It's called a tiered dispatch that's what you're looking for. If they have a problem with having enough ALS ambulances, the solution isn't increase the scope of a EMT, it's hire more paramedics or only use advanced EMTs. The scope of practice you are talking about is covered by advanced EMTs.


We do a tiered response with medics and basics on a lot of calls simply because you need the extra manpower. However, advanced EMT's are no longer a thing in my county. Hiring more medics is not getting any easier so if the city gets busy it's residence are SOL and I don't think that's fair.


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## VentMonkey (Aug 10, 2017)

taxidriver said:


> We do a tiered response with medics and basics on a lot of calls simply because you need the extra manpower. However, advanced EMT's are no longer a thing in my county. Hiring more medics is not getting any easier so if the city gets busy it's residence are SOL and I don't think that's fair.


And? @luke_31 is right. It's a national paramedic shortage. What would  a crash course in IV administration and/ or medication administration for your areas basics do to prolong life within your respective region?

You do realize what most paramedics do in the field, procedure-wise, remains in question with regards to being of any use at all to a patients overall quality of life, right?


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## taxidriver (Aug 10, 2017)

VentMonkey said:


> And? @luke_31 is right. It's a national paramedic shortage. What would  a crash course in IV administration and/ or medication administration for your areas basics do to prolong life within your respective region?
> 
> You do realize what most paramedics do in the field, procedure-wise, remains in question with regards to being of any use at all to a patients overall quality of life, right?


I'm gonna have to disagree. theres a number of emergencies that I believe basics should have the ability to run themselves. At the very least have the ability to run an arrest by themselves, deal with hypoglycemia, and give a patient fluids. Maybe if you were working the road when there was no ALS to respond to a pedestrian hit by a car because they were dealing with a "sick" patient your opinion would change.


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## DesertMedic66 (Aug 10, 2017)

taxidriver said:


> I'm gonna have to disagree. theres a number of emergencies that I believe basics should have the ability to run themselves. At the very least have the ability to run an arrest by themselves, deal with hypoglycemia, and give a patient fluids. Maybe if you were working the road when there was no ALS to respond to a pedestrian hit by a car because they were dealing with a "sick" patient your opinion would change.


Using a trauma patient to say why ALS is needed is not the best option. Trauma needs one thing and that is a non-delayed transport to an OR.


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## taxidriver (Aug 10, 2017)

DesertMedic66 said:


> Using a trauma patient to say why ALS is needed is not the best option. Trauma needs one thing and that is a non-delayed transport to an OR.


They also need fluid which as a basic I can't provide. I'm not preaching that this needs to be revised on a national level. I'm simply stating that are places in the US that need it.


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## VentMonkey (Aug 10, 2017)

@taxidriver your ideas of prehospital medicine are completely naive, ignorant, and convoluted. Try again when you have more experience.


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## taxidriver (Aug 10, 2017)

VentMonkey said:


> @taxidriver your ideas of prehospital medicine are completely naive, ignorant, and convoluted. Try again when you have more experience.


And you speak as if prehospital medicine is entirely pointless. Why do any of it? Why not just have an empty rig with a stretcher since anything we do in the field won't help a patient at all.


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## Flying (Aug 11, 2017)

Woah there. The folks that have responded to you have only implied that trauma in particular needs a particular response, fast transport to definitive care, fluids aren't exactly the priority.

I don't know much about fluid resuscitation myself, but I do know it has come under a lot of scrutiny for various reasons and I'm willing to bet that what you are suggesting is probably along the lines of the Vietnam-era modality, not the fluid-_restrictive_ one that is being touted today.

On top of that the things that you are suggesting that basics ought to be able to do are not benign procedures. Putting fluids into people and anything resembling decent arrest management are not things you can get away with without some sort of formal education, probably at least paramedic level education.


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## luke_31 (Aug 11, 2017)

taxidriver said:


> And you speak as if prehospital medicine is entirely pointless. Why do any of it? Why not just have an empty rig with a stretcher since anything we do in the field won't help a patient at all.


Statistically in a trauma situation that would be better then an ALS ambulance that stays on scene to get an IV for those precious fluids you are talking about.  Oh by the way fluids aren't very important in a trauma and have been shown to increase morbidity and mortality, the same as if you delay transport to the OR. A true trauma patient needs a surgeon and nothing less will make a significant impact on the patient living or dying.


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## taxidriver (Aug 11, 2017)

But at the end of the day, basics will not get dispatched to that call alone. Instead, an ALS unit that's twenty minutes will get it while the patient will still be on scene bleeding out. I just used that specific example because it's something that I have actually seen happen. Along with their greater set of skills Medics are also more educaeted and more experienced. When a mother throws her baby down the stairs out of rage of course what that baby is a trauma center and fast. I still don't want basics like myself with 3 months of schooling and a couple clinicles going on those calls.


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## VentMonkey (Aug 11, 2017)

taxidriver said:


> Maybe if you were working the road when there was no ALS to respond to a pedestrian hit by a car because they were dealing with a "sick" patient your opinion would change.


Oh, I have. Perhaps re-read my replies to your posts and maybe you'll realize just how foolish your approach sounds. Better yet, read the entire thread from the beginning if you haven't done so already; it was chocked full of posts by some rather articulate folks on this site.


taxidriver said:


> They also need fluid which as a basic I can't provide. I'm not preaching that this needs to be revised on a national level.


Nor should a basic be able to, because their knowledge is, well, basic. Again, you do not know what you do not know.


taxidriver said:


> I'm simply stating that are places in the US that need it.


Need what? Fluids? Trauma patients need cold, hard, sterile steel; nothing relatively new there. Definitive care is...defining.

The places you speak of (i.e., rural "middle of nowhere" America) often utilize air resources for this very reason. A faster mode of transportation...to get said trauma patient to the place that has cold, hard, sterile steel.


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## taxidriver (Aug 11, 2017)

Those statistics also don't change the fact that protocols are protocols. If a patient is bleeding out they need fluids according to my protocols and basics will not be getting that call for that reason. Now the scene to OR time is increased dramatically.


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## Flying (Aug 11, 2017)

taxidriver said:


> Those statistics also don't change the fact that protocols are protocols. If a patient is bleeding out they need fluids according to my protocols and basics will not be getting that call for that reason. Now the scene to OR time is increased dramatically.


That's a problem with medical direction and resource management, not EMTs not being able to do more.


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## taxidriver (Aug 11, 2017)

That's exactly right. The problem is within the 911 system and the reality of it is that some of them are really messed up. I'll run on people that took their insulin and forgot to eat all day and be happy. But when ALS is busy with all of that and a call comes up where they are actually needed, that patients gonna be waiting a ridiculous amount of time for a unit posted elsewhere to show up. Right now the standard is if you dial 911 you're getting ALS. When there are only two rigs covering an entire city this can be disasterous. I'm advocating that the emt-b class be extended and cover more just so the system can be more efficient. Imagine the mess Detroit would be in if they were an all ALS system. Luckily they aren't, they put their basics through an academy and give them the training they need to make the system more efficient. They're still a mess but they needed something like that and they aren't the only city where that would help.


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## VentMonkey (Aug 11, 2017)

taxidriver said:


> That's exactly right. The problem is within the 911 system and the reality of it is that some of them are really messed up. I'll run on people that took their insulin and forgot to eat all day and be happy. But when ALS is busy with all of that and a call comes up where they are actually needed, that patients gonna be waiting a ridiculous amount of time for a unit posted elsewhere to show up. Right now the standard is if you dial 911 you're getting ALS. When there are only two rigs covering an entire city this can be disasterous. I'm advocating that the emt-b class be extended and cover more just so the system can be more efficient. Imagine the mess Detroit would be in if they were an all ALS system. Luckily they aren't, they put their basics through an academy and give them the training they need to make the system more efficient. They're still a mess but they needed something like that and they aren't the only city where that would help.


Detroit isn't exactly the best example to utilize given their history. With that, if they're rebuilding for the better- good for them. Maybe your system expects this, but every system is unique in that it's separate from the next. 

For all the jokes about California that are made almost daily on here, my system doesn't expect it's basics to sit and twiddle their thumbs eternally waiting for the "heroics" that its medics possess in their bag-o-tricks, but instead supports logical thinking in the best interest of the patients health and well-being. Maybe _you_ need to find a different system.


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## taxidriver (Aug 11, 2017)

VentMonkey said:


> Detroit isn't exactly the best example to utilize given their history. With that, if they're rebuilding for the better- good for them. Maybe your system expects this, but every system is unique in that it's separate from the next.
> 
> For all the jokes about California that are made almost daily on here, my system doesn't expect it's basics to sit and twiddle their thumbs eternally waiting for the "heroics" that its medics possess in their bag-o-tricks, but instead supports logical thinking in the best interest of the patients health and well-being. Maybe _you_ need to find a different system.



Maybe, but if I worked anywhere else around me I'd be doing IFT's all day so I'm happy hehe. It's really just a sticky situation and I think someday someone is going die waiting for ALS instead of getting raced to the hospital. Maybe we disagree on how to fix that problem but I think we can all agree it's a problem that needs fixing.


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## Flying (Aug 11, 2017)

taxidriver said:


> Right now the standard is if you dial 911 you're getting ALS. When there are only two rigs covering an entire city this can be disasterous.


From what I've seen New Jersey is doing relatively fine with just basics and medics in their two-tier system. Many other states are also doing fine with just basics and medics in their respective systems. I've been told by a PHTLS educator that AEMTs were phased out of the state because adding a couple of extra skills to EMTs had no net positive effect on patient outcomes.

I think your county needs to hire additional medics, modernize their dispatch practices and introduce ALS intercepts and a number of other things, instead of having "911" level calls continue to wait on ALS and/or sort-of ALS.


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## DesertMedic66 (Aug 11, 2017)

taxidriver said:


> They also need *blood *which as a basic I can't provide. I'm not preaching that this needs to be revised on a national level. I'm simply stating that are places in the US that need it.


Fixed it for you


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## taxidriver (Aug 11, 2017)

DesertMedic66 said:


> Fixed it for you


The facts don't change protocols. This patient will still be bleeding out waiting for ALS that's half an hour away.


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## taxidriver (Aug 11, 2017)

Flying said:


> From what I've seen New Jersey is doing relatively fine with just basics and medics in their two-tier system. Many other states are also doing fine with just basics and medics in their respective systems. I've been told by a PHTLS educator that AEMTs were phased out of the state because adding a couple of extra skills to EMTs had no net positive effect on patient outcomes.
> 
> I think your county needs to hire additional medics, modernize their dispatch practices and introduce ALS intercepts and a number of other things, instead of having "911" level calls continue to wait on ALS and/or sort-of ALS.


I agree completely. The reason I was saying basics should have to go through a more rigourous education program is so that the system would have more confidence in us and realize that not all calls need ALS. If the 911 dispatching system can simply modernize on its own then great, but I don't see it happening. That just might be the way she goes.


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## DesertMedic66 (Aug 11, 2017)

taxidriver said:


> The facts don't change protocols. This patient will still be bleeding out waiting for ALS that's half an hour away.


Of bleeding can not be controlled by BLS means there is very little I am going to be able to do as ALS. If it’s internal bleeding I am not going to be cutting them open to stop the bleed. If I give this patient a ton of fluid all I am doing is thinning the blood out and making it so that they can not clot as well and flooding their body with a volume replacement that has zero oxygen carrying capacity. Also I will be unintentionally cooling the patient down. A cold trauma patient who’s blood can not clot and can not carry oxygen = a dead patient.


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## VentMonkey (Aug 11, 2017)

taxidriver said:


> The facts don't change protocols. This patient will still be bleeding out waiting for ALS that's half an hour away.


Yikes. You are in no way A) making a valid case and argument for why basics in your area need to be able to start IV's, and are B) postulating with a grandiose amount of caution to the wind. 

When I think of articulate, and trustworthy basics on here @DrParasite, @EpiEMS, and @NysEms2117 come to mind. I highly doubt any of them would advocate for such rubbish at their respective provider level. But hey? I could be flat out wrong; it's happened before, and it will happen again, and again.


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## taxidriver (Aug 11, 2017)

I'm not saying I disagree with you. I understand it would be much better to Just slap some o2 on the patient and boogie. But if protocols state they need fluid then they are going to get fluid, basics will not be getting that call. So while all the cities medics are out giving sugar to diabetics and checking up on people who called because of hypotension that patient that needs to get to the hospital will be waiting and waiting and waiting.


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## VentMonkey (Aug 11, 2017)

@taxidriver, ya lost me. But citing "if protocols say..." doesn't work with the more astute paramedic providers. You're making reference to the notoriously dubious "cookie-cutter" paramedic; you don't want to be _that_ medic...ever.


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## gonefishing (Aug 11, 2017)

taxidriver said:


> The facts don't change protocols. This patient will still be bleeding out waiting for ALS that's half an hour away.


I've had some serious GSW victims in the past and managed at a BLS provider level with no issues.  I managed the bleeding, transported the pt and they made it.  They got an IV after the fact and they in fact lived.  Time is something that matters.  ALS providers are not gods nor are they witch doctors.   With my GSW patients ive had in the past it was package load and go.  You can do everything in the back you would do on that street corner while your partner hauls butt and be able to take them to a facility with all the hands, care providers, tools that they would require.  I had a pt shot up like swiss cheese.  Patched and controlled bleeding, my als was 5 minutes away.  IV or not he died right there on the street with us working on him.  Nothing als could do.

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## Flying (Aug 11, 2017)

I really don't see why the system needs to adopt a hodge podge solution because you don't think a certain type of policy change can be affected.

What I'm seeing is this: "The protocols won't change, therefore an inefficient solution [that is more likely to be rejected than a change in protocol] is needed to circumvent that."


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## taxidriver (Aug 11, 2017)

Exactly, but basics aren't getting those calls in my system. I really do agree with what everyone is saying but basics will not get any sort of trauma or time sensitive calls alone. My idea is only an attempt to make ALS more available so response times are increased for the patients that need to go.


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## gonefishing (Aug 11, 2017)

taxidriver said:


> Exactly, but basics aren't getting those calls in my system. I really do agree with what everyone is saying but basics will not get any sort of trauma or time sensitive calls alone. My idea is only an attempt to make ALS more available so response times are increased for the patients that need to go.


Some of my gsw calls were still alarms.  I've had em where they get blasted and stumble to your ambulance as your taking cover.

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## VentMonkey (Aug 11, 2017)

taxidriver said:


> Exactly, but basics aren't getting those calls in my system. I really do agree with what everyone is saying but basics will not get any sort of trauma or time sensitive calls alone.


how unfamiliar are you with the New York City EMS system, and its overwhelming amount of call volume?


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## taxidriver (Aug 11, 2017)

VentMonkey said:


> how unfamiliar are you with the New York City EMS system, and its overwhelming amount of call volume?


I know they're a busy department and if there was any way to make sure that were enough units capable of getting the job done I'd be all for it.


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## taxidriver (Aug 11, 2017)

I feel many of you misunderstand what I'm trying to say. To summarize, give basics the ability to run more of the easy BS calls so that ALS is available and doesn't have to come from 20-30 minutes away. All I'm saying.


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## NysEms2117 (Aug 11, 2017)

taxidriver said:


> Exactly, but basics aren't getting those calls in my system. I really do agree with what everyone is saying but basics will not get any sort of trauma or time sensitive calls alone. My idea is only an attempt to make ALS more available so response times are increased for the patients that need to go.



I'd guarantee that as a basic working 24 hrs a month, I see more "trauma or time sensitive calls" then most medics would I'm also a nys emt-b. Nothing more, nothing less. The point before about als being forever away, my pal @EpiEMS has said this countless times on various different threads there's a wonderful thing called ALS intercept. Or if your hours from a hospital, call HEMS, then you get outstanding providers like ventmonkey, chase, and summit, who know more about healthcare then I do if I'm allowed to use google... I sit on both sides of reform, if people want to make paramedic the minimum, I see the logic and im not offended. I haven't used my EMT-B knowledge more then 10 times working, I say this all the time... it is COMMON SENSE, they're bleeding, try to stop that. If they aren't breathing try to assist them in breathing. If you can't, call somebody that can. 
I think a major problem is when people graduate emt-b class and get there certificate they think it's a giant accomplishment, which it is, however it's an accomplishment that needs to be put in perspective. 


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## NysEms2117 (Aug 11, 2017)

taxidriver said:


> I feel many of you misunderstand what I'm trying to say. To summarize, give basics the ability to run more of the easy BS calls so that ALS is available and doesn't have to come from 20-30 minutes away. All I'm saying.



Have you ever been able to watch a paramedic work a trauma case?? If not, I want to to go observe a paramedic and I think any good paramedic (like most of the ones on this site) would say they bls before als. Starting an iv on a person that's been dead for 10 minutes doesn't do a damn thing. Trying to start an iv on a person that's been shot 4 times before controlling breathing doesn't do a damn thing.

Where I work my medic partner does his assessment, then either tells me what to do if it's a bls maneuver OR tells me what to get. The fact of the matter is, chances are you can always do something... 


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## NomadicMedic (Aug 11, 2017)

I went on a GSW Wednesday night that was BLS all the way. My system sent TWO paramedic units. :/

We'll get it figured out eventually.


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## DesertMedic66 (Aug 11, 2017)

taxidriver said:


> I feel many of you misunderstand what I'm trying to say. To summarize, give basics the ability to run more of the easy BS calls so that ALS is available and doesn't have to come from 20-30 minutes away. All I'm saying.


A good place to start would be to utilize an EMD system that can serve several functions such as: sending the appropriate resources (ALS or BLS) with an appropriate response/priority (lights and sirens or normal driving), and also have the ability to tell people over the phone that no ambulance will be sent out for your stubbed toe. 

We just starting doing a somewhat EMD system and it’s working out ok. However all 911 calls are still ALS. 

I have never worked in a system that uses paramedic fly cars/SUVs but from reading a lot of posts from people who are in that system it seems to be a good option.


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## GMCmedic (Aug 11, 2017)

DesertMedic66 said:


> A good place to start would be to utilize an EMD system that can serve several functions such as: sending the appropriate resources (ALS or BLS) with an appropriate response/priority (lights and sirens or normal driving), and also have the ability to tell people over the phone that no ambulance will be sent out for your stubbed toe.
> 
> We just starting doing a somewhat EMD system and it’s working out ok. However all 911 calls are still ALS.
> 
> I have never worked in a system that uses paramedic fly cars/SUVs but from reading a lot of posts from people who are in that system it seems to be a good option.


Ive said it before. EMD would be great, if the entire system werent designed around leading questions. 

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## NomadicMedic (Aug 11, 2017)

PMDS (priority medical dispatch) doesn't ask leading questions, but does have some questions that can change a call determinant from BLS to ALS. For example, a stable nursing home patient that needs to be seen at the ED would code as as a 33 Bravo, but as soon as the dispatcher asks, "has this patient been evaluated by a medical professional?" and the CNA calling says "Yes", its upgraded to a 33 Charlie, which puts ALS on it. Does it need ALS? Probably not. But that's a glitch in the system. 

Medical directors have the option to adjust responses and call determinants, but it's an involved process and many departments just install the EMD protocol set as it comes off the shelf and consider it "good enough". If you have issues or questions with your EMD Protocols, you should get involved with the committee that oversees EMD QI. It'll be an eye opening experience


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## EpiEMS (Aug 11, 2017)

In an urban setting, there is evidence (also see here and here) to suggest that penetrating trauma benefits more from rapid transport by police than waiting for EMS. Heck, I'd argue that BLS care is likely as good as ALS (if not better, because it's cheaper) for most trauma in the urban setting.



NomadicMedic said:


> I went on a GSW Wednesday night that was BLS all the way.



I'm almost getting to the point where I think that penetrating trauma without airway & breathing complications should only get a BLS unit dispatched.


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## Summit (Aug 11, 2017)

taxidriver said:


> I feel many of you misunderstand what I'm trying to say. To summarize, give basics the ability to run more of the easy BS calls so that ALS is available and doesn't have to come from 20-30 minutes away. All I'm saying.


Reading the convoluted logic you used to to support these points, why people didn't focus on your primary points in discussion is obvious. In trying to support your points, you made arguments that seemed reveal large deficiencies in your understanding of evidenced based practice and philosophy of care, the types of deficiencies that reveal the pitfalls of giving EMTs more.

You have a resource utilization and system philosophy issue. Fix the underlying problem.


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## taxidriver (Aug 11, 2017)

Sounds like many of you are looking at the problem as if it's a perfect world. I was hardly even making a medicine related argument, I'm arguing for efficiency and getting people the help they need when they call. Basics running any 911's is still very taboo in my area. Even when we bring in patients from nursing homes for low hemoglobin levels you can hear the doctors chatting with eachother "Why are there so many basics in the ER?" If you understood how hospitals and our dispatch system viewed basics then you would understand why i thought that the logical thing to do was to make basics more educated and give them a higher skill set. I still think this would help considering the only other opposing arguments were that trauma patients don't need fluid.


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## taxidriver (Aug 11, 2017)

Summit said:


> Reading the convoluted logic you used to to support these points, why people didn't focus on your primary points in discussion is obvious. In trying to support your points, you made arguments that seemed reveal large deficiencies in your understanding of evidenced based practice and philosophy of care, the types of deficiencies that reveal the pitfalls of giving EMTs more.
> 
> You have a resource utilization and system philosophy issue. Fix the underlying problem.


That's weird considering I'm not arguing to change the kind of treatment people get. Just to make sure they get the care they need and quickly. We run ALS trucks medic-medic. Most nights theres only two of them covering a city of 60,000. Basics will not get any sort of Emergencies if ALS won't be making it on scene first. ALS intercept is not a thing since for the most part there's usually a hospital 5-10 minutes  away but nevertheless, BLS will not have anything to do with that call. Instead a unit covering a dif city will be pulled in. Seriously, if anyone has a better solution I'm all ears. I'm not trying to be ignorant or act as if I know more than the more experiences folks here but no one presented a different solution.


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## VentMonkey (Aug 11, 2017)

@taxidriver without being too much more of a Richard, you're lacking one of the most fundamental things one can when debating on this forum- experience; both in the field and out of it.

You're misreading others replies as well, and telling me (us) that I (we) view things with a perfectionists perspective. Most of us are fairly well experienced in life, and in the field; I'm pretty sure we realize things will never be perfect. How else would we have survived this industry long enough to see another starry-eyed, young naive EMT suggest what's already been suggested? 

There isn't anything wrong with being new, and full of ideas; aren't we all at some point? It's what makes every profession grow. But we are telling you--from experience--you're way off base, and have no clue what you are talking about.

Also, maybe learn how to clarify your point a little better. You're confusing me, and I don't even possess half the knowledge, grammatically (or other), that some of these folks with bachelors and masters degrees do.


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## GMCmedic (Aug 11, 2017)

taxidriver said:


> That's weird considering I'm not arguing to change the kind of treatment people get. Just to make sure they get the care they need and quickly. We run ALS trucks medic-medic. Most nights theres only two of them covering a city of 60,000. Basics will not get any sort of Emergencies if ALS won't be making it on scene first. ALS intercept is not a thing since for the most part there's usually a hospital 5-10 minutes  away but nevertheless, BLS will not have anything to do with that call. Instead a unit covering a dif city will be pulled in. Seriously, if anyone has a better solution I'm all ears. I'm not trying to be ignorant or act as if I know more than the more experiences folks here but no one presented a different solution.


Run medic/basic trucks instead. 

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## taxidriver (Aug 11, 2017)

Although Detroit has a messed up EMS system and they aren't the best example they fixed themselves a lot lately and I'm sugg w


GMCmedic said:


> Run medic/basic trucks instead.
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk


That's probably more likely to happen than anything I've suggested. Still, it's a grey area. A lot of the medics don't think of basics as competent enough and don't want to do all the work in the back for a whole shift so it's still rare to see.


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## NysEms2117 (Aug 11, 2017)

taxidriver said:


> A lot of the medics don't think of basics as competent enough


why should they? Basics took a 200 hour express worst case scenario class. as previously mentioned, people like @VentMonkey and @Summit should be primary providers in the field. I (as an emt basic) do not know nearly enough. Your 19, you have a lot to learn, and room to grow, just take advice these folks are giving you. They have been doing it for YEARS. If you don't want my advice fine, i've only been doing it for a year and a half, but do know this... I listen first, *especially* if its something i don't know much of anything about.

Edit: It's all about knowing where you fit into the system, and acting accordingly with said role. I work on a critical care rig, so most of what i do is getting what my medic partner needs... thats my job.


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## Summit (Aug 11, 2017)

@taxidriver The point here is that EMTs should NOT be sitting on scene 30 minutes waiting for ALS. They should load and proceed to definitive care or an ALS intercept. That is a very basic and easy to solve systems problem.

Resource utilization issues you have described are complex to solve, but the above quick solution will help address the extreme cases you provide as examples.

The philosophy of care that you should understand, and was hit on by Vent was, practicing EMS as if protocols were the gospel to the detriment of the patient is the worst kind of healthcare philosophy you can embrace.

There is plenty of philosophy to discuss regarding additional skills vs additional education. How is time best spent? Where was time spent for AEMT? The market has not been fond of AEMT. I think there is a thread discussing the merits of IV access as an addon skill for EMTs somewhere...


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## EpiEMS (Aug 11, 2017)

taxidriver said:


> Basics will not get any sort of Emergencies if ALS won't be making it on scene first.



This is pretty confusing - so if there is a free BLS unit, but no free ALS units, the BLS unit will not be dispatched?


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## taxidriver (Aug 11, 2017)

EpiEMS said:


> This is pretty confusing - so if there is a free BLS unit, but no free ALS units, the BLS unit will not be dispatched?


Yep. They will instead pull an ALS unit that's further out. They won't let us start doing our job without ALS over our shoulder.


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## MonkeyArrow (Aug 11, 2017)

taxidriver said:


> Yep. They will instead pull an ALS unit that's further out. They won't let us start doing our job without ALS over our shoulder.


So, uh, what do you when you get on scene first? Sit in the truck waiting for ALS?


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## NysEms2117 (Aug 11, 2017)

MonkeyArrow said:


> So, uh, what do you when you get on scene first? Sit in the truck waiting for ALS?


perfect time to take selfies! and play games!


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## taxidriver (Aug 11, 2017)

MonkeyArrow said:


> So, uh, what do you when you get on scene first? Sit in the truck waiting for ALS?


We don't get on scene first. We either get dispatched with ALS thats at the same post as us or we don't.


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## DrParasite (Aug 12, 2017)

taxidriver said:


> Right now the standard is if you dial 911 you're getting ALS.


 pretty sure that's not the standard... The standard is an ambulance will arrive. In Delaware it's a BLS ambulance.  In New Jersey, it's a BLS ambulance.  In Boston and NYC, it's a BLS ambulance.  Unless the call meets the criteria for ALS, than ALS is sent too.


taxidriver said:


> When there are only two rigs covering an entire city this can be disasterous.


 you think that's bad... I now live in a state that has counties that have only four ambulances county wide, including one if the worst small cities in the US (or so the web reports say).  And others without a hospital in the county.

 I'm sure you can imagine how the a bodies aren't lining up on the side of the road....


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## DrParasite (Aug 12, 2017)

taxidriver said:


> Basics running any 911's is still very taboo in my area.... I still think this would help considering the only other opposing arguments were that trauma patients don't need fluid.


ok, what area are you referring to? SoCal?

And trauma patients don't need fluid: they need bright lights and cold steel, which a paramedic can't provide.


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## taxidriver (Aug 12, 2017)

May not be the standard in your area but it is in mine. And I know trauma patients need an OR. protocol in my area states they need fluid, that means they are only going to send units capable of providing that to those scenes.


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## Summit (Aug 12, 2017)

Again, you have a systems issue, not an "EMTs need more skills" issue.


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## DrParasite (Aug 12, 2017)

taxidriver said:


> May not be the standard in your area but it is in mine. And I know trauma patients need an OR. protocol in my area states they need fluid, that means they are only going to send units capable of providing that to those scenes.


Sounds like your system has an issue..... If you have a patient who is bleeding out, and you pump them full of fluid, all you are going to do is have pink koolaid on the floor of your ambulance.  Maybe your system should look at the studies that say that trauma patient don't need a paramedic?  And scoop and run will save more lives than IV fluid or any paramedic.

Maybe once your system catches up with the rest of the world, you can join the table with the big boys?  

Oh, and where is your system, that delays appropriate patient care in trauma patients because they want to make sure they get IV fluid?  I mean, if that's your standard, I just want to know what areas of the country I should avoid getting shot or stabbed in....


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## reaper (Aug 12, 2017)

Yes, your system needs to be updated. But, unless you can make that happen, why not step back and ask yourself what can I do? 
You could become a medic, so your system would have one more available! You could research, learn and present a report to your director on changes that could help.

You also need to stop thinking in what ifs! There are going to be pts that die while waiting for a unit to be available. You live in a town of 60k people. So unless you have 60k units in the road, there is always a chance someone will have to wait. That is just life and you accept it. 

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## Bullets (Aug 14, 2017)

EpiEMS said:


> I'm almost getting to the point where I think that penetrating trauma without airway & breathing complications should only get a BLS unit dispatched.



As a BLS provider, 10 minutes is the maximum time i want to spend on scene with a patient who m taking to trauma. I can do 99% of my job in the back of the rig, so however long it takes to do my rapid assessment, control and massive hemorrhage and package is ideal. If ALS is there by then, great, get in and let boogie. If not, oh well. With the advent of better blind airways, i really dont see the need for ALS on most calls. Unless its some kind of neck injury that would require a tricky tube or a cric, all ALS is doing is giving TXA. 

The issues that TaxiDriver is discussing are systemic issues, not national issues. I dont feel that there is anything i need in my BLS scope to better handle trauma patients. Maybe iGels. But i rarely have instances were i need a better airway than an NPA.


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## EpiEMS (Aug 14, 2017)

Bullets said:


> I dont feel that there is anything i need in my BLS scope to better handle trauma patients.


I'd agree with that. I think BLS providers could use a bit more in the way of medical skills (e.g. CPAP, albuterol) in national scope.


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## Medic27 (Aug 14, 2017)

I am only an EMT not a paramedic, but I feel like it could be useful if EMR's (I'm not super familiar with their curriculum) could use a c-collar / very basic until EMS arrives. What about an OPA airway? I feel like it's basic enough an EMR could manage? Anyone agree, disagree? Why?


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## VentMonkey (Aug 14, 2017)

Medic27 said:


> I am only an EMT not a paramedic, but I feel like it could be useful if EMR's (I'm not super familiar with their curriculum) could use a c-collar / very basic until EMS arrives. What about an OPA airway? I feel like it's basic enough an EMR could manage? Anyone agree, disagree? Why?


Better yet, do away with EMR altogether. There's hardly a need for a basics basic.

If you want to learn first aid, take a first aid course. Otherwise, sit through the whopping couple of hundred hours, learn all of the above skills in proper fashion, and pass registry like everyone else.


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## Medic27 (Aug 14, 2017)

VentMonkey said:


> Better yet, do away with EMR altogether. There's hardly a need for a basics basic.
> 
> If you want to learn first aid, take a first aid course. Otherwise, sit through the whopping couple of hundred hours and pass registry like everyone else.


I understand this but I think the EMR cirriculum is an important role in terms of police officers or other civilians that don't want to take the next step into diving deeper. I think of police officers and city officials when I think of EMR. Do you disagree?


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## EpiEMS (Aug 14, 2017)

VentMonkey said:


> and pass registry like everyone else.



But EMRs have a registry exam - in many states, it is an 80 hour course, which is pretty good for cops & firefighters that don't perform EMS as a primary duty. The EMR level captures takes the most important BLS skills that can be done prior to EMS arrival - CPR/AED, BVM, hemorrhage control, etc. & adds background above what a first aid class does. Yes, I'd rather have folks take the EMT class, but, again, for single-role cops, firefighters, lifeguards, etc., EMR is appropriate.


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## Medic27 (Aug 14, 2017)

EpiEMS said:


> But EMRs have a registry exam - in many states, it is an 80 hour course, which is pretty good for cops & firefighters that don't perform EMS as a primary duty. The EMR level captures takes the most important BLS skills that can be done prior to EMS arrival - CPR/AED, BVM, hemorrhage control, etc. & adds background above what a first aid class does. Yes, I'd rather have folks take the EMT class, but, again, for single-role cops, firefighters, lifeguards, etc., EMR is appropriate.


I think all firefighters should be an EMT, but then again fire and ems respond as one in my area to medical calls. Majority of which EMT-A or Paramedics.


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## VentMonkey (Aug 14, 2017)

CPR, and basic first aid--moreover hemorrhage control--is all law enforcement in theory needs to know. AED use prior to EMS? Sure, but I can't see any of this taking 80 hours collectively. 

Babies have been delivered for centuries prior to the advent of these courses. That's hardly a skill so much so as maternal, and paternal instincts.


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## DesertMedic66 (Aug 14, 2017)

I am still a fan of having EMR as a level of training especially for LEO, lifeguards, search and rescue, security guards, etc when obtaining an EMT cert or having a medical director is not an option.


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## Medic27 (Aug 14, 2017)

VentMonkey said:


> CPR, and basic first aid--moreover hemorrhage control--is all law enforcement in theory needs to know. AED use prior to EMS? Sure, but I can't see any of this taking 80 hours collectively.
> 
> Babies have been delivered for centuries prior to the advent of these courses. That's hardly a skill so much so as maternal, and paternal instincts.





DesertMedic66 said:


> I am still a fan of having EMR as a level of training especially for LEO, lifeguards, search and rescue, security guards, etc when obtaining an EMT cert or having a medical director is not an option.


Absolutely, do you think basic air management can be taught in that span or would you disagree?


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## EpiEMS (Aug 14, 2017)

@VentMonkey Including practical skills time, I don't think 80 hours is so crazy - but maybe it's more like 40-60? The educational guidelines for EMR go beyond a basic first aid class, at least, based on my experience with the AHA & Red Cross.


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## DesertMedic66 (Aug 14, 2017)

Medic27 said:


> Absolutely, do you think basic air management can be taught in that span or would you disagree?


Normally basic airway management is included in the EMR class.


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## Medic27 (Aug 14, 2017)

DesertMedic66 said:


> Normally basic airway management is included in the EMR class.


Oh, I was unaware. That's good to know, is o2 administration included or do they defer that to the EMT?


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## EpiEMS (Aug 14, 2017)

Medic27 said:


> Oh, I was unaware. That's good to know, is o2 administration included or do they defer that to the EMT?


By NRB & NC, definitely.


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## Medic27 (Aug 14, 2017)

EpiEMS said:


> By NRB & NC, definitely.


Great to know! I was unaware.


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## VentMonkey (Aug 14, 2017)

EpiEMS said:


> @VentMonkey Including practical skills time, I don't think 80 hours is so crazy - but maybe it's more like 40-60? The educational guidelines for EMR go beyond a basic first aid class, at least, based on my experience with the AHA & Red Cross.


Right, but how proficient does an LEO, or even big city firefighter have to be in order to perform said skills in the few minutes it will take to wait for the medics and EMT's to arrive?

Why push for EMR, but not AEMT? To me, the only levels of certified prehospital providers needed are EMT and paramedic as it would appear all other providers (i.e., EMR, and AEMT) have become befuddled with no real applicable efficacy. 

Most of what's been proven to prolong life is the very basics. Why else could one's life be prolonged by their own relative if said relative was taught proper CPR? None of this needs to be taught correctly,_ but then_ certified to death.

I am well aware of the educational advancements needed in our industry, and many of you know which side of this debate I am on. But, if we can't even figure out how or why we should be focusing on practical, and logical matters when talking specific certifications what's it matter? 

EMR is like a pseudo-EMT. Hmmm, what's an AEMT to a paramedic??...


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## Medic27 (Aug 14, 2017)

VentMonkey said:


> Right, but how proficient does an LEO, or even big city firefighter have to be in order to perform said skills in the few minutes it will take to wait for the medics and EMT's to arrive?
> 
> Why push for EMR, but not AEMT? To me, the only levels of certified prehospital providers needed are EMT and paramedic as it would appear all other providers (i.e., EMR, and AEMT) have become befuddled with no real applicable efficacy.
> 
> ...


The answer to your first question there are very rural sections in my state where it can take 40 minutes code 3 for ALS to arrive with only two EMR's in that city. That would depend on the need for population and EMTs/LE available. Where do you draw the line? It's hard. I don't think anyone can give a definitive answer.


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## VentMonkey (Aug 14, 2017)

Medic27 said:


> There are very rural sections in my state where it can take 40 minutes code 3 for ALS to arrive with only two EMR's in that city.


And there are some very strong opinions on this board about people living in very rural America. Use the search button, this is hardly a new topic.


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## Medic27 (Aug 14, 2017)

VentMonkey said:


> And there are some very strong opinions on this board about people living in very rural America. Use the search button, this is hardly a new topic.


I will sometime I am a little newer to the forum.


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## DrParasite (Aug 14, 2017)

Medic27 said:


> I understand this but I think the EMR cirriculum is an important role in terms of police officers or other civilians that don't want to take the next step into diving deeper. I think of police officers and city officials when I think of EMR. Do you disagree?


Until you get people like this https://emtlife.com/threads/emergency-medical-responder.46117/ who think EMR should be a certification that you should get paid to do....


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## Medic27 (Aug 14, 2017)

DrParasite said:


> Until you get people like this https://emtlife.com/threads/emergency-medical-responder.46117/ who think EMR should be a certification that you should get paid to do....


That is so much BS I don't even wanna go into it... I think EMT basics hardly have a place, but they do in some areas. It is ridiculous to think an EMR would be paid, I don't know where that person found that idea but no... EMT/EMR for a baby sitter job to make them more prepared? Great idea, for a job as an "EMR", in itself? I don't think so. Like said it's literally a 40 hour course, EMT for me was 140. Take 4 weeks out of your life to take an EMT course and then go jump on a rig after passing the NREMT if you want to make a career out of EMS.


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## VentMonkey (Aug 14, 2017)

Medic27 said:


> That is so much BS I don't even wanna go into it... I think EMT basics hardly have a place, but they do in some areas. It is ridiculous to think an EMR would be paid, I don't know where that person found that idea but no... EMT/EMR for a baby sitter job to make them more prepared? Great idea, for a job as an "EMR", in itself? I don't think so. Like said it's literally a 40 hour course, EMT for me was 140. Take 4 weeks out of your life to take an EMT course and then go jump on a rig after passing the NREMT if you want to make a career out of EMS.


But you were just advocating for EMR?

Also, once our eldest daughter hits babysitting age I hardly find the need for her to have to become an EMR in order for my wife and I to feel safe leaving her alone with other little gremlins.

Common sense goes so much farther in life than any nifty rescue course, or cool patch. It is your reaction to life's curveballs that will show your "heroic worth", not a cert.


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## Medic27 (Aug 14, 2017)

VentMonkey said:


> But you were just advocating for EMR?
> 
> Also, once our eldest daughter hits babysitting age I hardly find the need for her to have to become an EMR in order for my wife and I to feel safe leaving her alone with other little gremlins.
> 
> Common sense goes so much farther in life than any nifty rescue course, or cool patch. It is your reaction to life's curveballs that show your "heroic worth", not a cert.


I think EMR's can serve a purpose alongside another speciality (police, wildland fire, swat, e.g.) , I definitely don't advocate for them getting paid for that alone. I absolutely agree with your last statement but if you are someone wanting to make a career owning your own daycare or watching children it would help install confidence in the parents. I don't know why would ever put EMR's on trucks they wouldn't know what to do with themselves. EMR is a separate entity from an EMT, the only real difference in 100 hours - 120 hours. If you want to be an EMT become one, move to Baton Rouge or anywhere basics are on hot demand and you will get a job. An EMR will not.


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## VentMonkey (Aug 14, 2017)

Medic27 said:


> If you are someone wanting to make a career owning your own daycare or watching children it would help install confidence in the parents.


It has had no bearing on which daycare my wife and I have chosen for our girls. 

None of the daycares around us have EMR's working for them. I promise you none of the well-to-do parents I know care anything about this silly certification. The biggest word in any parents vocabulary with daycare is- trustworthiness.


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## Summit (Aug 14, 2017)

First Responder (now called EMR) is a great level for those who don't provide patient care as their primary role. As I mentioned previously, most people take an AFA class because it is a faster or an EMT class so they can work in EMS.

What I tend to see is the Wildernest First Responder which is the FR content + wilderness care in about 80 hours. Some places do offer the WFR with the ability to sit for NR-EMR, but not many... there is just about no demand for the NREMT EMR cert. The certification granted by WFR education agencies (CMC, DMM, SOLO, WMI, WMA, etc) is considered good enough by agencies that utilize WFR.

Day care I expect to have first aid and CPR


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## Medic27 (Aug 14, 2017)

VentMonkey said:


> It has had no bearing on which daycare my wife and I have chosen for our girls.
> 
> None of the daycares around us have EMR's working for them. I promise you none of the well-to-do parents I know care anything about this silly certification. The biggest word in any parents vocabulary with daycare is- trustworthiness.


Alright well I guess we live on different sides of the Mississippi or something because I know several people with EMR's who are in child care or work in a school.


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## EpiEMS (Aug 14, 2017)

VentMonkey said:


> Right, but how proficient does an LEO, or even big city firefighter have to be in order to perform said skills in the few minutes it will take to wait for the medics and EMT's to arrive?



As far as the basic skills, I would say they need to be fairly proficient. Think about BVM use - that's not an easy skill to master, but it is awfully helpful if you're ventilating an overdose. Having a certified level of proficiency helps HR departments, for one, but it also helps to ensure a baseline level of competence.



VentMonkey said:


> Why push for EMR, but not AEMT? To me, the only levels of certified prehospital providers needed are EMT and paramedic as it would appear all other providers (i.e., EMR, and AEMT) have become befuddled with no real applicable efficacy.



I'm actually a big fan of the AEMT concept - I think it ought to be our entry level transporting EMS provider, and also should be pushed for rural area services (career, volunteer, or hybrid). EMR is kind of like AEMT insofar as that it tries to bridge the gap (skill gap, availability gap, etc.).



VentMonkey said:


> Most of what's been proven to prolong life is the very basics. Why else could one's life be prolonged by their own relative if said relative was taught proper CPR? None of this needs to be taught correctly,_ but then_ certified to death.



I'm all for training people, but without an independent certification process, it's hard to verify competency.


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## VentMonkey (Aug 14, 2017)

EpiEMS said:


> I'm all for training people, but without an independent certification process, it's hard to verify competency.


Because clearly we have done a stellar job eliminating incompetence from this field thus far?


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## Medic27 (Aug 14, 2017)

VentMonkey said:


> Because clearly we have done a stellar job eliminating incompetence from this field thus far?


I think we all know an EMT who shouldn't be an EMT, I know I have.


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## VentMonkey (Aug 14, 2017)

Medic27 said:


> I think we all know an EMT who shouldn't be an EMT, I know I have.


Right, or an EMR, medic, etc., etc., etc.

Verifying skills competency in a climate controlled environment from a sequentially drawn up sheet on a mannequin works just fine...until it doesn't.

If we, as a group, want to advocate AEMT being the minimum, then basics should go the way of the dinosaur, yes? Not have a revised set of national protocols. 

All that's fine, but there really is no need for more than two prehospital provider levels, so long as they're truly designed to compliment one another and not stifle each other with overlapping skill sets, and knowledge. 

Then again, illogically defining our profession based soley on the skills that each certificate possesses is also not a new concept to American prehospital providers. 

It's hardly medicine in this sense, and predominantly ego.


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## Medic27 (Aug 14, 2017)

VentMonkey said:


> Right, or an EMR, medic, etc., etc., etc.
> 
> Verifying skills competency in a climate controlled environment from a sequentially drawn up sheet on a mannequin works just fine...until it doesn't.
> 
> ...


Absolutely, I agree I just hope as an EMT I would be eligible to to advance to an AEMT with no cost.


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## EpiEMS (Aug 14, 2017)

VentMonkey said:


> Because clearly we have done a stellar job eliminating incompetence from this field thus far?



Fair enough. Initial certification is a minimum level of competence, and competence has to be carefully evaluated in different contexts (agency FTOs, chart reviews, etc.). I don't think we can ever fully eliminate incompetent people in any field - but we certainly need to reduce the ability of our testing to monitor for incompetence.



VentMonkey said:


> If we, as a group, want to advocate AEMT being the minimum, then basics should go the way of the dinosaur, yes? Not have a revised set of national protocols.



Not necessarily -- it could just be used to raise the floor, as it were, if we ratchet up the standards. For example, we could say "Ok, now the baseline for first responders has to be the EMT level."



VentMonkey said:


> All that's fine, but there really is no need for more than two prehospital provider levels, so long as they're truly designed to compliment one another and not stifle each other with overlapping skill sets, and knowledge.



I don't disagree - but as our levels are designed now, EMT & paramedic are fundamentally different jobs, so I'm not sure that EMT & paramedic are the levels to keep, unless EMT is the first response (non-transport) level & paramedic is the only transporting level. (Perhaps keeping EMTs for IFT.)


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## Summit (Aug 14, 2017)

I wonder why AEMT hasn't become more popular. Employers could easily demand it for new providers at virtually no premium over an experienced EMT.


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## Medic27 (Aug 14, 2017)

Summit said:


> I wonder why AEMT hasn't become more popular. Employers could easily demand it for new providers at virtually no premium over an experienced EMT.


From what I hear it's not very popular in the East... Idk why... In Idaho EMTs can get advanced modules IV/IO administration and do a lot of things AEMTs can do @ the discretion of our medical director.


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## EpiEMS (Aug 14, 2017)

Summit said:


> I wonder why AEMT hasn't become more popular. Employers could easily demand it for new providers at virtually no premium over an experienced EMT.



I agree...and they can bill more, too (ALS1 billing). Of course, in many places, paramedics are easy to come by.


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## reaper (Aug 14, 2017)

A lot of it comes down to the class. Why do AEMT, when you can do Paramedic with just two extra semesters.

I think in out service we have two AEMTs out of 280 employees. Most EMT-Is upgraded to Paramedic and a few downgraded to Basic. 

If you are going to spend the time and money, do what is better for you and your pts. Just go to Paramedic!

Sent from my VS985 4G using Tapatalk


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## Medic27 (Aug 14, 2017)

reaper said:


> A lot of it comes down to the class. Why do AEMT, when you can do Paramedic with just two extra semesters.
> 
> I think in out service we have two AEMTs out of 280 employees. Most EMT-Is upgraded to Paramedic and a few downgraded to Basic.
> 
> ...


Some people aren't sure if they can handle the kind of curriculum, myself included. I may go advanced before paramedic and ride some years as an EMT-B before moving to EMT-A and then Paramedic. I am 18, so it's hard for me to put myself in the role of a paramedic at this age or 1 year from now. I'm almost 19, but if I ever did paramedic I would want to be 22-24. I think it's important to have at least a level below that. Just imo..


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## reaper (Aug 14, 2017)

One of the best young medics I know, had his medic by 19. I watched him study and push himself. He now does fixed wing. 



Sent from my VS985 4G using Tapatalk


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## Bullets (Aug 14, 2017)

EpiEMS said:


> I'd agree with that. I think BLS providers could use a bit more in the way of medical skills (e.g. CPAP, albuterol) in national scope.



I forget that some states arent giving their EMTs these skills yet, but yeah, i agree.


Medic27 said:


> From what I hear it's not very popular in the East... Idk why... In Idaho EMTs can get advanced modules IV/IO administration and do a lot of things AEMTs can do @ the discretion of our medical director.



Because its not needed. My county has 5 hospitals, one is a Level II trauma unit. One town in this county has a 30 minute ride to two level 2s and a level one. I have 5 24hr ALS trucks, 2 part time trucks, and a 24hr truck from an adjacent county that covers part of mine as a primary. Up to 8! ALS units are available for my county.
 600k people live in 500sq miles. So thats less than 100k people and 70sq miles per truck. I rarely wait for ALS and they are pretty quick to get to use.

We are at the transition between suburban and rural (for NJ), the closer you get the the cities (NYC and Philly) the more concentrated the Hospitals and ALS get. We also have 13 helicopter flying around our state, plus the Coasties, PLUS NYPD who have been know to jump flights on Sandy Hook and the bay area. 

Theres just so many hospitals, ALS units, HEMS, Coasties and such that there really isnt a need for an intermediate level of care


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## DrParasite (Aug 15, 2017)

Bullets said:


> 600k people live in 500sq miles. So thats less than 100k people and 70sq miles per truck. I rarely wait for ALS and they are pretty quick to get to use.


 don't you deal with the evil empire primarily?  I have heard horror stories about them, particularly when it comes to a rapid ALS response, particularly how it's far from rapid and control has some retards staffing it (and also some good friends of mine who aren't retarded)....


Bullets said:


> We are at the transition between suburban and rural (for NJ), the closer you get the the cities (NYC and Philly) the more concentrated the Hospitals and ALS get. We also have 13 helicopter flying around our state, plus the Coasties, PLUS NYPD who have been know to jump flights on Sandy Hook and the bay area.


you remember when it was just northstar and southstar?  ahhh, memories.....  and yes, now NJ is so inundated with helicopters, that there isn't a call volume to support them all.  and 80% of all EMS calls in NJ are still handled without a paramedic.


Bullets said:


> Theres just so many hospitals, ALS units, HEMS, Coasties and such that there really isn't a need for an intermediate level of care


respectfully disagree.  There are numerous calls I can remember where I wish I could have dropped a king airway, or checked a BGL (or even given sugar), or given albuterol on a wheezing patient..... or benadryl for a minor allergic reaction.  I recall one particular day (I think I was working for Linden EMS at the time, and I think somehow we ended up by Carteret), when the patient has having an allergic reaction to something, not at the level of needing epi, but did need some benedryl....  And we had to wait for a paramedic unit from Rahway or Perth to give the patient benedryl....Oddly enough, all these skills are in my scope of practice as an EMT in NC....

NC just revamped their EMT program, and it is a minimum of 190 hours (166 hours of didactic and 24 hours of clinical time). There is no maximum level as per the state.  We have a state wide EMR program (which is 80 hours), and some of the volunteer fire departments couldn't do that, so they have a county version first responder program. 

If it was up to me, I'd get rid of the EMR program altogether, and make the minimum level of prehospital training EMT.  If they need something to help out the EMTs, they can take an 8 hour first aid course.  The EMRs can transition to EMTs (with a 110 hour transition course), but after that, be done with it.  I still support volunteers, and the volunteer system, provided they are able to provide the same services as their career counterparts.  Same levels of training, same equipment (I will let the response times slide a little bit due to the nature of some rural systems), and same competencies, but if they can't do it, than it's time to replace them with someone who can.


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## DrParasite (Aug 15, 2017)

EpiEMS said:


> I don't disagree - but as our levels are designed now, EMT & paramedic are fundamentally different jobs, so I'm not sure that EMT & paramedic are the levels to keep, unless EMT is the first response (non-transport) level & paramedic is the only transporting level. (Perhaps keeping EMTs for IFT.)


Ehhhhhhhh  how are they fundamentally different?  They both pick people up, stabilize them to the best of their ability, and take them to definitive care.  Yes, one has a lot of tools to chose from, and a lot more interventions to give, but they do similar jobs, and there are still plenty of states that run tiered systems where not every ambulance has a paramedic on it....

I would like to see EMT be the basic first response level, and AEMT and paramedic be paired up for the ALS ambulance.  Maybe even make it EMT and paramedic, where the EMT needs to become an AEMT within 2 years as a condition of employment.  But in my experience, the majority of calls in EMS don't require a paramedic, they need a proper assessment to confirm the patient won't die during the transport, followed by a comfy ride to the hospital.


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## Medic27 (Aug 15, 2017)

Bullets said:


> I forget that some states arent giving their EMTs these skills yet, but yeah, i agree.
> 
> 
> Because its not needed. My county has 5 hospitals, one is a Level II trauma unit. One town in this county has a 30 minute ride to two level 2s and a level one. I have 5 24hr ALS trucks, 2 part time trucks, and a 24hr truck from an adjacent county that covers part of mine as a primary. Up to 8! ALS units are available for my county.
> ...


Lol try coming to Idaho, but I also like the NW best our medical scope as a whole is less stringent


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## johnrsemt (Aug 15, 2017)

Where I work PT, the Advanced can run a full code;  they do all but about 6 of the Medic Level Meds,  can't intubate, or cric or needle decompress.  Other states don't use them at all.
Education wise (certificate) is about 1/2 of paramedic and a lot less money


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## Medic27 (Aug 15, 2017)

johnrsemt said:


> Where I work PT, the Advanced can run a full code;  they do all but about 6 of the Medic Level Meds,  can't intubate, or cric or needle decompress.  Other states don't use them at all.
> Education wise (certificate) is about 1/2 of paramedic and a lot less money


Which states are we talking about "Other states don't use them at all." ... At least where I am from we have some of the lenient scopes of practice (Idaho), I can't think of more than half a dozen times where our main county has needed a cric, tbh even a needle decompression. Although, intubation may be within the scope of practice and I have seen it done firsthand, (I realise not all the time can we wait)  but it seems like a lot of these are last resort efforts. I do like your area how they employee EMTs and Paramedics.


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## reaper (Aug 15, 2017)

Medic27 said:


> Which states are we talking about "Other states don't use them at all." ... At least where I am from we have some of the lenient scopes of practice (Idaho), I can't think of more than half a dozen times where our main county has needed a cric, tbh even a needle decompression. Although, intubation may be within the scope of practice and I have seen it done firsthand, (I realise not all the time can we wait)  but it seems like a lot of these are last resort efforts. I do like your area how they employee EMTs and Paramedics.


But, this comment shows why you need educated providers. None of the treatments you listed are "last resort". If they are needed, they are needed right away. This comes down to the old saying, just because you can do a skill, doesn't mean you know why you are doing it!

Sent from my VS985 4G using Tapatalk


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## Medic27 (Aug 15, 2017)

reaper said:


> But, this comment shows why you need educated providers. None of the treatments you listed are "last resort". If they are needed, they are needed right away. This comes down to the old saying, just because you can do a skill, doesn't mean you know why you are doing it!
> 
> Sent from my VS985 4G using Tapatalk


Understandably so but you can't put a paramedic or a pair in every city in the US... I don't know about you, but 90-95% of calls I have gone on typically aren't emergencies. I think you were missing my point. In terms of budget I would rather have them spread out equally versus only in the county. Like said many states can't even do those skills. Here a paramedic can do a paracardiocentesis in the field, it doesn't mean they should....


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## EpiEMS (Aug 15, 2017)

Medic27 said:


> Understandably so but you can't put a paramedic or a pair in every city in the US.



Well, that's not true...it just depends on what resources municipalities choose to allocate to EMS.


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## Medic27 (Aug 15, 2017)

EpiEMS said:


> Well, that's not true...it just depends on what resources municipalities choose to allocate to EMS.


Sure, but I don't see this being accomplished anytime soon? Not impossible, but you are going to have a ton of interior politics to deal with.


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## EpiEMS (Aug 15, 2017)

Medic27 said:


> Sure, but I don't see this being accomplished anytime soon? Not impossible, but you are going to have a ton of interior politics to deal with.



Certainly true! But we can't claim that cities *can't* staff EMS effectively, it's more that they "won't".


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## VentMonkey (Aug 15, 2017)

Medic27 said:


> Understandably so but you can't put a paramedic or a pair in every city in the US... I don't know about you, but 90-95% of calls I have gone on typically aren't emergencies. I think you were missing my point. In terms of budget I would rather have them spread out equally versus only in the county. Like said many states can't even do those skills. Here a paramedic can do a paracardiocentesis in the field, it doesn't mean they should....


Clarify, because your "point" is awful confusing to me. I don't think you're understanding the bigger picture of EMS and its logistics.

How long have you actively been in, and around this field? Have you sat in on any meetings at any EMS departments, or taken any EMS management courses?

With all due respect, I don't think you have a clue what you are talking about. @reaper had a good point when he mentioned levels of education. 

A good paramedic understands why they should not be doing something long before jumping into a procedure and can, with hardly batting an eye, recognize when something taught but not often performed needs to take place. You cannot (and should not) condense this into a shorter course; the coursework should be extended.

As it stands now, our national curriculums educational standards, even at the advance provider levels, are severely lacking.


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## Medic27 (Aug 15, 2017)

EpiEMS said:


> Certainly true! But we can't claim that cities *can't* staff EMS effectively, it's more that they "won't".


Agreed, with this though taxes would increase. Not all paramedics work full-time, and we can't staff a small little city generating barely enough to keep the town hall going lol


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## reaper (Aug 15, 2017)

Seen it happen in FL years ago. The state mandated ALS coverage in every county. Now, there were some rural counties that only had two ALS trucks and a few BLS trucks, but they still had Paramedic coverage when needed. 

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## DrParasite (Aug 15, 2017)

Medic27 said:


> Understandably so but you can't put a paramedic or a pair in every city in the US... I don't know about you, but 90-95% of calls I have gone on typically aren't emergencies


The other argument is, with a paramedic in every city, and 90% of those call are not emergencies, how many truly sick patients will be seen by those paramedics?  

Remember, if the paramedic is the specialist, and the specialist doesn't see patients in need of their specialty, how sharp will they be then they have dealt with 95 taxi rides, and then they get the train wreck?


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## reaper (Aug 15, 2017)

Medic27 said:


> Agreed, with this though taxes would increase. Not all paramedics work full-time, and we can't staff a small little city generating barely enough to keep the town hall going lol


Then do away with the town hall! Would you not think that EMS should take precedent over a meeting place? 
Cities and counties love to cry they cannot afford it. But, they can afford all the other crap! If needed raise the property tax. I have never lived any where that I would complain about my taxes raising slightly. If it meant better medical coverage for the citizens.

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## DrParasite (Aug 15, 2017)

Medic27 said:


> Agreed, with this though taxes would increase. Not all paramedics work full-time, and we can't staff a small little city generating barely enough to keep the town hall going lol


so raise the taxes..... I am not in favor of arbitrarily raising them, but if you have a good reason to....

does the police department work full time?  how about the garbage collectors/ department of public works?  maybe someone in the school system?  Let me put it even simpler: does any employee work full time for the township?  If the answer is yes, than the blunt truth is the town CAN hire full time paramedics.  Whether they CHOOSE to is a different story.

It's all about budgeting.  Too many government bodies (towns, county, etc) have gotten away with free EMS (for various reasons, and using various methods) for so long that they balk at having to pay for it.  You CAN afford them, but you will need to reallocate funds to this service.  yes, that means someone else will need to work on a tighter budget, but it can be done, if you WANT to.


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## VentMonkey (Aug 15, 2017)

@Medic27 I can appreciate your enthusiasm for this industry. Maybe take some college courses--say in--economics and college-level sciences, get your degree(s), all while gaining field experience and before you know it you'll be ready for paramedic school.

I guarantee you'll be light years ahead of your classmates, and even a lot of people on here...including myself.


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## Bullets (Aug 15, 2017)

DrParasite said:


> don't you deal with the evil empire primarily?  I have heard horror stories about them, particularly when it comes to a rapid ALS response, particularly how it's far from rapid and control has some retards staffing it (and also some good friends of mine who aren't retarded)....


Yeah but this is largely dependent on the crews. Some are more....motivated than others



> respectfully disagree.  There are numerous calls I can remember where I wish I could have dropped a king airway, or checked a BGL (or even given sugar), or given albuterol on a wheezing patient..... or benadryl for a minor allergic reaction.  I recall one particular day (I think I was working for Linden EMS at the time, and I think somehow we ended up by Carteret), when the patient has having an allergic reaction to something, not at the level of needing epi, but did need some benedryl....  And we had to wait for a paramedic unit from Rahway or Perth to give the patient benedryl....Oddly enough, all these skills are in my scope of practice as an EMT in NC....



I dont disagree that there are some things we should add to the EMT scope, but i still dont think we need three levels of certification in NJ. I would say BGLs and Nebs, and changing the epi policy to allow drawing up instead of autoinjectors. Maybe IM bendryl and glucagon. Nebs and Epi are in subcomitee right now so that might change soon.


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## DrParasite (Aug 15, 2017)

I would agree that expanding the BLS scope of practice would be better than adding an intermediate level.  And I wasn't even referring to IM benedryl, all the patient needed was OTC benadryl....

and I would still be in favor of a BLS Supraglottic Airway device to use on cardiac arrests.... again, just to match up with the national standards...  again, just my opinion on that one ... and I am good with a OPA and BVM


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## Bullets (Aug 15, 2017)

DrParasite said:


> I would agree that expanding the BLS scope of practice would be better than adding an intermediate level.  And I wasn't even referring to IM benedryl, all the patient needed was OTC benadryl....
> 
> and I would still be in favor of a BLS Supraglottic Airway device to use on cardiac arrests.... again, just to match up with the national standards...  again, just my opinion on that one ... and I am good with a OPA and BVM


I wouldnt be surprised if the iGel becomes the standard for prehospital arrest. It was discussed at the last BLS subcommittee and has mixed support with some of the bigger medical directors


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## EpiEMS (Dec 14, 2017)

Updates: https://www.nasemso.org/Projects/EM...-Practice-Model-Revision-Draft2-12Dec2017.pdf

They're seeking comments!


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## Summit (Dec 14, 2017)

Paramedic said:
			
		

> 195 Program Level:
> 196 Academic. Diploma, Certificate, Associate, Baccalaureate, or Masters Degree awarded for successful completion.
> 197 Critical Thinking
> 198 Advanced/complex decision making, protocol assisted.



Now is the time press them on phasing out diploma/certificate for new medics. Make it an associates degree!


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## EpiEMS (Dec 14, 2017)

Summit said:


> Now is the time press them on phasing out diploma/certificate for new medics. Make it an associates degree!



I wrote a comment noting that the rest of the Anglosphere uses a bachelors for entry to practice...


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