# Difference between BLS and ALS calls?



## patzyboi (Jan 4, 2013)

I know procedures and scope of practices are different, and how they are difference. But what is the difference in having BLS and ALS calls? 

For example, in an EMT and paramedic unit, if there is a "BLS" call, the paramedic will sometime drive, and let the EMT do the patient care work.

Thing is, isnt everything the EMT do can be improved with paramedic work?


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## EMT B (Jan 4, 2013)

patzyboi said:


> Thing is, isnt everything the EMT do can be improved with paramedic work?



However godly they may seem to you, there are some things that they just cant fix in the field. prime example is a patient with an AAA. they need a surgeon, not a medic.


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## NYMedic828 (Jan 4, 2013)

patzyboi said:


> I know procedures and scope of practices are different, and how they are difference. But what is the difference in having BLS and ALS calls?
> 
> For example, in an EMT and paramedic unit, if there is a "BLS" call, the paramedic will sometime drive, and let the EMT do the patient care work.
> 
> Thing is, isnt everything the EMT do can be improved with paramedic work?



Absolutely nothing is different between an ALS and BLS call. What is different is the assessment and treatment parameters of the provider on that call.

When the paramedic drives, odds are they have a very stable patient who just needs a taxi ride to the ER.

Yes, a paramedic may do everything an EMT can do. A paramedic SHOULD be far better in their assessment, treatment and differential diagnosis.


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## DesertMedic66 (Jan 4, 2013)

Unless you are in some places in California where if there is a medic on the ambulance the medic has to take the call regardless if its ALS or BLS.


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## VFlutter (Jan 4, 2013)

Both have lights and sirens and that is all that matters h34r:


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## leoemt (Jan 5, 2013)

I routinely take patients that in all honesty should probably go ALS. Problem is we have so few Medics and the county doesn't allow private medics. Fortunately, I am close to a bunch of hospitals so as long as I can get them there alive then they are in good hands. 

Stabbings, unconscious trauma, Hypoglycemia DLOC, Anaphalaxis, etc. They all ride in my ambo.


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## mycrofft (Jan 5, 2013)

patzyboi said:


> I know procedures and scope of practices are different, and how they are difference. But what is the difference in having BLS and ALS calls?
> 
> For example, in an EMT and paramedic unit, if there is a "BLS" call, the paramedic will sometime drive, and let the EMT do the patient care work.
> 
> Thing is, isnt everything the EMT do can be improved with paramedic work?



CHange a tire?


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## abckidsmom (Jan 5, 2013)

I ride with BLS partners. Say we get a psych call. BLS right? Say my inexperienced partner says the wrong thing, puts his foot in his mouth, does nothing good for the patient, and magnifies the problem, whatever it is. 

I have about 20 times the experience, and 50 times the education in dealing with psych problems. 

Who has the responsibility if the patient goes crazy and jumps out the back of the truck?

Who is going to lose sleep at night?

Yeah, I tech in most of the calls. I'm not a paragod type. I really am not. But I don't love the idea of choosing to let inexperienced, undereducated providers "practicing" unsupervised on real sick people. They deserve our best.


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## mycrofft (Jan 5, 2013)

abckidsmom said:


> Yeah, I tech in most of the calls. I'm not a paragod type. I really am not. But I don't love the idea of choosing to let inexperienced, undereducated providers "practicing" unsupervised on real sick people. They deserve our best.



Of any rating, right?


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## AnthonyTheEmt (Jan 5, 2013)

leoemt said:


> I routinely take patients that in all honesty should probably go ALS. Problem is we have so few Medics and the county doesn't allow private medics. Fortunately, I am close to a bunch of hospitals so as long as I can get them there alive then they are in good hands.
> 
> Stabbings, unconscious trauma, Hypoglycemia DLOC, Anaphalaxis, etc. They all ride in my ambo.




I hope you're kidding about that. Most of those, if not all, are ALS calls. Especially the anaphylaxis. Absolutely NOT a BLS call


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## Aidey (Jan 5, 2013)

No, he isn't kidding. He works in Seattle, and Medic One is well known for pulling stuff like that.


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## DesertMedic66 (Jan 5, 2013)

AnthonyTheEmt said:


> I hope you're kidding about that. Most of those, if not all, are ALS calls. Especially the anaphylaxis. Absolutely NOT a BLS call



As the poster said he/she is close to many hospitals. Transporting to a hospital is a better idea then waiting for ALS if the hospital is closer.


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## Aidey (Jan 5, 2013)

Half the time ALS are the ones who have dumped the pt on the BLS crew...


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## EpiEMS (Jan 5, 2013)

leoemt said:


> Stabbings, unconscious trauma, Hypoglycemia DLOC, Anaphalaxis, etc. They all ride in my ambo.



The good news is penetrating trauma patients need transport more than anything else -- BLS measures are just a bonus (http://www.ncbi.nlm.nih.gov/pubmed/21166730, http://theemtspot.com/2011/03/12/should-we-let-the-cops-transport-our-patients/).

Also, ALS doesn't really do much as far as broad, system-wide outcomes in trauma (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292763/, http://www.ncbi.nlm.nih.gov/pubmed/17975392). 

And ALS probably doesn't do much for getting us functioning people back post-arrest. It just produces more brain-dead warm bodies. http://roguemedic.com/2011/12/cardiac-arrest-management-is-an-emt-basic-skill-the-bls-evidence/ and sundry other Rogue Medic posts with great citations for those who are interested).

Granted, yes, ALS is great for lots of medical problems. But for many of the high acuity sort of things we think about EMS being responsible for (penetrating trauma, cardiac arrest), BLS is as good or better than ALS as far as patient outcomes go.

Don't get me wrong, I love having ALS. Pain management is very important, as are several other ALS core competencies. But we need to keep in mind that many of the things we *think* ALS would or should do better at are actually better done with BLS measures (or even just rapid transport without any care en route).


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## Akulahawk (Jan 5, 2013)

Back in the time before time (before I was a medic), I sometimes had to transport the sickest of the sick, those patients that I should otherwise have no business transporting without a medic. I would do it because I could get the patient to an advanced level of care (ED) faster than I could get an advanced level of care to the patient (medic). Believe me, many times I'd much rather just give the patient over to ALS if I could have... I never did it simply because I could. I worked with some EMT's that did it just because they could get away with it. Fortunately, those guys never pushed the boundaries that much... though other companies allowed it. 

Never a good idea for an EMT to take patients that require care above what they can deliver unless they absolutely have to...


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## Sandog (Jan 5, 2013)

abckidsmom said:


> I ride with BLS partners. Say we get a psych call. BLS right? Say my inexperienced partner says the wrong thing, puts his foot in his mouth, does nothing good for the patient, and magnifies the problem, whatever it is.
> 
> I have about 20 times the experience, and 50 times the education in dealing with psych problems.
> 
> ...



Now these statements just irk me. What makes you think an EMTB has less education anyways? I am just a basic, and I have a degree in biology, as well a engineering background, and did I mention 6 years in the Navy.

How about treating basics as something other than under educated half wits.

Really... :angry:


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## Sandog (Jan 5, 2013)

Sorry, having a bad day, just found out my 7 mo. old dog has some congenital bone condition in his hip.


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## Thricenotrice (Jan 5, 2013)

EpiEMS said:


> The good news is penetrating trauma patients need transport more than anything else -- BLS measures are just a bonus (http://www.ncbi.nlm.nih.gov/pubmed/21166730, http://theemtspot.com/2011/03/12/should-we-let-the-cops-transport-our-patients/).
> 
> Also, ALS doesn't really do much as far as broad, system-wide outcomes in trauma (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292763/, http://www.ncbi.nlm.nih.gov/pubmed/17975392).
> 
> ...



Could not disagree more. How about judging on WHERE a patient should go, especially working in a high population like Seattle with I'm sure many different receiving types. Are your assessment skills strong enough to determine the best destination vs killing a pt because you took them to an inadequate facility? So on and so forth? Could go on and on. I was an EMT for 3 years in a busy system before going to medic school, so I'm not just paramedic thinking.

Bls is the basic stuff and definitely necessary, but do not discount the paramedic assessment and treatment. The only exception I can think of is a trauma situation where you are within minutes of a trauma center or capable hospital and they did not need some sort of resuscitation (as far as "Als" calls go)


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## Aidey (Jan 5, 2013)

Sandog said:


> Now these statements just irk me. What makes you think an EMTB has less education anyways? I am just a basic, and I have a degree in biology, as well a engineering background, and did I mention 6 years in the Navy.
> 
> How about treating basics as something other than under educated half wits.
> 
> Really... :angry:



Dana is also an RN. And since when did a background in engineering and biology degree help someone manage a psych pt appropriately?


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## Sandog (Jan 5, 2013)

Aidey said:


> Dana is also an RN. And since when did a background in engineering and biology degree help someone manage a psych pt appropriately?



That really has nothing to do with my point about basics being undereducated, or the myth being perpetuated that they are, but whatever...


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## Medic Tim (Jan 5, 2013)

Sandog said:


> Now these statements just irk me. What makes you think an EMTB has less education anyways? I am just a basic, and I have a degree in biology, as well a engineering background, and did I mention 6 years in the Navy.
> 
> How about treating basics as something other than under educated half wits.
> 
> Really... :angry:





Sandog said:


> That really has nothing to do with my point about basics being undereducated, but whatever...



For the most part they are.... Where I volly there is a basic with  a degree and it is night and day difference compared to those with no other education. The others I take just about every call as I am responsible for the pt. There are many that are satisfied with doing the bare minimum. MAybe it is location dependant but I have seen very few basics with and associates degree let alone a bachelors.
It is no myth that emt education is lacking. It is also true that medic education is lacking but there is a big difference between a couple hundred hours and a couple thousand.

Sorry to hear that about your dog.


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## Thricenotrice (Jan 5, 2013)

Sandog said:


> That really has nothing to do with my point about basics being undereducated, or the myth being perpetuated that they are, but whatever...



I work as a basic right now, and I have only worked with one good partner (education/common knowledge wise) in the past 4 months. He was a failed medic student. Not saying that all basics  are dumb, but there is definitely not a good case out there right now, at least in my area. 
That's roughly 45 shifts with countless partners. I would not want a family/friend sick or injured in the county which I work. 

There are always exceptions and different circumstances. This is just my experience.


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## Sandog (Jan 5, 2013)

Yet, that is a generalization, and yet I know many people that have their basics and are still advancing their skill set with schooling.  For me, EMT was just an ends to a mean. to reach my objective.

My point is, quit assuming basics are Xbox playing no nothings, and stop portraying basics as such in post.

I am sure I could learn much from medics, but at the same time I am sure they could learn from me.

Bottom line is, treat your basic with respect, educate your basic, and in the long run, realize your a team. Make your basic an asset to you and those you serve.


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## Sandog (Jan 5, 2013)

Thricenotrice said:


> I work as a basic right now, and I have only worked with one good partner (education/common knowledge wise) in the past 4 months. He was a failed medic student. Not saying that all basics  are dumb, but there is definitely not a good case out there right now, at least in my area.
> That's roughly 45 shifts with countless partners. I would not want a family/friend sick or injured in the county which I work.
> 
> There are always exceptions and different circumstances. This is just my experience.



I am sure there are many bad basics, as well as medics, but that is not to say all basics are bad, and are know nothings.

Recipe for success:

Give basics respect until they do not deserve it.


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## leoemt (Jan 5, 2013)

AnthonyTheEmt said:


> I hope you're kidding about that. Most of those, if not all, are ALS calls. Especially the anaphylaxis. Absolutely NOT a BLS call



Per Protocol Anaphalaxis is a BLS call with either ALS Eval or transport to ER for DR eval. We carry Epi Pens for a reason. Yes, I have given one. 

We don't have enough medics to come to every boo boo and owie. Believe it or not BLS stands for Basic Life Support, not Taxi. 

I can manage all of those calls for the 5 minutes it will take me to get to the ER. ANY complications, or indications and I will get a Medic. My protocol manual has very few ALS indicators in it. Most of which are Cardiac or Airway related. 

ABC's.


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## the_negro_puppy (Jan 5, 2013)

leoemt said:


> Per Protocol Anaphalaxis is a BLS call with either ALS Eval or transport to ER for DR eval. We carry Epi Pens for a reason. Yes, I have given one.
> 
> We don't have enough medics to come to every boo boo and owie. Believe it or not BLS stands for Basic Life Support, not Taxi.
> 
> ...



Epi-Pen / adrenaline / epinephrine is not the only treatment for anaphylaxis. But you are quite- quick transport is often under-estimated. As medics we tend to stay and play a bit more because of all the drugs and tools were carry. Sometimes this can be extremely beneficial for the patient. Other times detrimental.


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## abckidsmom (Jan 5, 2013)

Sandog said:


> Yet, that is a generalization, and yet I know many people that have their basics and are still advancing their skill set with schooling.  For me, EMT was just an ends to a mean. to reach my objective.
> 
> My point is, quit assuming basics are Xbox playing no nothings, and stop portraying basics as such in post.
> 
> ...



I make no such assumptions. I base my decisions off of real life experience with actual people. Some are great, some are 19 yo guys who had a semester long course in high school and can't believe they are living the dream. 

There are a whole range of people, and I am speaking of the reality in my situation. There are so many different people out there, if your experience is only with driven, smart, aware and thinking basics, you really haven't seen the half of it.


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## Bullets (Jan 5, 2013)

Thricenotrice said:


> Could not disagree more. How about judging on WHERE a patient should go, especially working in a high population like Seattle with I'm sure many different receiving types. Are your assessment skills strong enough to determine the best destination vs killing a pt because you took them to an inadequate facility? So on and so forth? Could go on and on. I was an EMT for 3 years in a busy system before going to medic school, so I'm not just paramedic thinking.



You really think it requires a paramedics level of training to determine where to take a patient?  You must have some classically stupid providers in your system...

If you are out in the country you probably only have one option as a hospital

If you are in the cities, you have 5-6 options and most do everything. In NYC every hospital is a Trauma center...where i work every hospital can handle STEMI, CVA, and Trauma.

Since ive been here my view of ALS has expanded and i have been keeping them on calls my younger self would have loaded and went. My inital thinking went like this

2-3 Minutes for medics, they assess and treat fr 5-10, 5 minute transport=at best 12 minutes, usually more like 20 before we hit the door at the ER.

Cancel medics, 1 minute to the ambulance, 5 minute transport= 5 minutes till the door

A medic then said that on scene, the provider to patient ratio is usually 4:1 in the hospital its more like 1:10.

So ive been holding medics on scene and waiting, only to have them show up, connect the LP15 draw bloods and stare at the patient while we transport, and im thinking "Shoot, i could have done this without the IV (which the hospital is gong to pull anyway)"

Or just this week, i had a classic closed midshaft femur fracture, patient was lying on her side with minimal pain at rest, i got medics, hoping they could give a little pain before we reduce this with the traction splint and carry her up a narrow staircase. Medics arrive and upon hearing what i want reply "Thats not going to happen"

So i subjected my patient to pain while this Medic unit literally held analgesics  in their hands but wouldnt even try to get permission to administer it.


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## NYMedic828 (Jan 5, 2013)

Bullets said:


> You really think it requires a paramedics level of training to determine where to take a patient?  You must have some classically stupid providers in your system...
> 
> If you are out in the country you probably only have one option as a hospital
> 
> ...



I would have written them up/filed a complaint.


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## Bullets (Jan 5, 2013)

NYMedic828 said:


> I would have written them up/filed a complaint.



My medical director is not their medical director and they have a different OLMC. However i did shoot my MD and email and asked him to review the chart

After consulting with my MD, apparently their OLMC is about 90 miles north of where we are in a urban setting. The doctors there deal with a lot of drug seekers so they are not inclined to give orders for analgesics for fear of giving a drug seeker a high. Basically they only give the orders for things like amputations or multiple long bone fractures


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## systemet (Jan 5, 2013)

Bullets said:


> After consulting with my MD, apparently their OLMC is about 90 miles north of where we are in a urban setting. The doctors there deal with a lot of drug seekers so they are not inclined to give orders for analgesics for fear of giving a drug seeker a high. Basically they only give the orders for things like amputations or multiple long bone fractures



Wow! So a single long bone fracture does cut it any more? Personally,  I don't agree with trying to identify drug seekers prehospitally. I've got to say, though, if this guy's broken his own femur to get pain meds he probably earned them, and hardly counts as a drug seeker any more. Sounds like poor providers and a medical director just collecting a pay cheque (at least an unethical paramedic has the excuse that most of us never took ethics).


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## medichopeful (Jan 5, 2013)

Sandog said:


> That really has nothing to do with my point about basics being undereducated, or the myth being perpetuated that they are, but whatever...



Coming from a basic, we are WAY under educated!  It's kind of scary that they release us on the world with, to put it bluntly, first aid training.


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## JPINFV (Jan 5, 2013)

Sandog said:


> Now these statements just irk me. What makes you think an EMTB has less education anyways? I am just a basic, and I have a degree in biology, as well a engineering background, and did I mention 6 years in the Navy.
> 
> How about treating basics as something other than under educated half wits.
> 
> Really... :angry:



1. When talking about specific fields, you have to be specific to that field. Someone who has a PhD in Womyns Studies has more education than you, but that doesn't mean that you would let Dr. Womyn Studies take over for you when they have no EMS training. 

2. Basic science degrees provide an excellent jumping off point both for applied education (like paramedic training, and both for self an formal studying), however it does not, on its own, make an EMT able to practice as a paramedic.

3. Ditto for military experience. Actually, why is it that people who were employed by the military all of a sudden think they don't have to jump through the same hoops or that it gives them some sort of divine knowledge about anything and everything? Ok, congrats, you did a handful of advanced procedures on a group of people that, by and large, are very healthy when it comes to chronic diseases. You know, a population that's completely different than the non-military population. 

So, yes, when talking about EMS specifically, the only thing that matters is the amount of training in emergency medicine, emergency nursing, or EMS.


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## NYMedic828 (Jan 5, 2013)

systemet said:


> Wow! So a single long bone fracture does cut it any more? Personally,  I don't agree with trying to identify drug seekers prehospitally. I've got to say, though, if this guy's broken his own femur to get pain meds he probably earned them, and hardly counts as a drug seeker any more. Sounds like poor providers and a medical director just collecting a pay cheque (at least an unethical paramedic has the excuse that most of us never took ethics).



I see bullet mentioned NYC, so I am going to assume this took place within NYC.

In NYC, medics seem to think that administering analgesia is beneath them and not worth their time. They would rather let you suffer and take you to the hospital.

Thank god I am officially done with them.


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## AnthonyTheEmt (Jan 5, 2013)

leoemt said:


> Per Protocol Anaphalaxis is a BLS call with either ALS Eval or transport to ER for DR eval. We carry Epi Pens for a reason. Yes, I have given one.
> 
> We don't have enough medics to come to every boo boo and owie. Believe it or not BLS stands for Basic Life Support, not Taxi.
> 
> ...



So what?! You carry a damn epi pen! You don't carry advanced airway equipment for when their airway closes? Think outside the box. Anaphylaxis is more than just allergic reaction. It's a true ALS emergency!


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## Bullets (Jan 5, 2013)

NYMedic828 said:


> I see bullet mentioned NYC, so I am going to assume this took place within NYC.
> 
> In NYC, medics seem to think that administering analgesia is beneath them and not worth their time. They would rather let you suffer and take you to the hospital.
> 
> Thank god I am officially done with them.




Not in the City, but not far south. 

BLS calls are things that require no treatment or minimal treatment. They are most often simply "Im Sick" and they want to go to the hospital because they feel like it. And you could also include simple falls on sidewalks, from beds and chairs, commodes, ect, and seizures with a history. Everything else is most likely an ALS call.


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## NYMedic828 (Jan 5, 2013)

AnthonyTheEmt said:


> So what?! You carry a damn epi pen! You don't carry advanced airway equipment for when their airway closes? Think outside the box. Anaphylaxis is more than just allergic reaction. It's a true ALS emergency!



Wo brah. Who pissed in your cereal this morning?

Gonna have someone write a script for Xanax.



For the record, an epinephrine injection is the only proven effective treatment (as far as I know) in the presence of true anaphylaxis.

Benadryl and corticosteroids are all secondary treatments that may not have any worth in that stage of the condition. (KellyB wrote a blog entry on it somewhere)

Sure you can intubate but many BLS services have supraglottic airways now too. You can argue that intubation is more effective for ventilation but the bronchiconstriction is not localized to the upper airway. To my knowledge it mimics an asthmatic response and if you ever tried to ventilate a constricted asthmatic it doesn't work so wonderfully. Epinephrine to reverse the underlying cause is what matters.


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## EpiEMS (Jan 5, 2013)

medichopeful said:


> Coming from a basic, we are WAY under educated!  It's kind of scary that they release us on the world with, to put it bluntly, first aid training.



I totally, totally, totally agree with this one.



AnthonyTheEmt said:


> So what?! You carry a damn epi pen! You don't carry advanced airway equipment for when their airway closes? Think outside the box. Anaphylaxis is more than just allergic reaction. It's a true ALS emergency!



Intramuscular epinephrine is the gold standard of treatment for anaphylaxis (http://www.ncbi.nlm.nih.gov/pubmed/11692118, http://millhillavecommand.blogspot.com/2012/08/new-guidelines-for-anaphylaxis.html). Not to mention that there is evidence that people don't even THINK to use epi as the first line treatment (http://www.ncbi.nlm.nih.gov/pubmed/22712745).

Yes, ALS is great -- start a line, give some fluids, give some diphenhydramine, but epinephrine IM is more important.


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## Tigger (Jan 5, 2013)

Just have to hope there are enough epi pens on board, right?


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## systemet (Jan 5, 2013)

EpiEMS said:


> Yes, ALS is great -- start a line, give some fluids, give some diphenhydramine, but epinephrine IM is more important.



To a point, though, right?

A supraglottic airway may help if they're horribly bronchspastic, but in that situation we might want some combivent, mag, IV ventolin, etc. We may also get stuck in that horrible place where BVM isn't effective, but we need drugs to place an ET or SGA.

What if they're profoundly hypotensive? We might need a lot of fluid, maybe even some dope or glucagon.

What if the early benadryl or steroids is makes a critical difference at + 1 hour in the ER or ICU?

What if the patient's stridorous? Do we want some nebulised epi as well? Do we want to risk early intubation? Is a cricothyrotomy the best way to manage the airway?

What if they're pre-code? Do we want the ability to push IV epi or run an epi drip?

Yes, IM epi is the cornerstone of treatment,  but it's not the only therapy nor is it going to work if the patient isn't perfusing their vastus.


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## leoemt (Jan 5, 2013)

AnthonyTheEmt said:


> So what?! You carry a damn epi pen! You don't carry advanced airway equipment for when their airway closes? Think outside the box. Anaphylaxis is more than just allergic reaction. It's a true ALS emergency!



Have you ever seen Anaphylaxis in the field? Do you know the physiological process behind it? As mentioned Epinepherine is the gold standard for treatment. But hey I guess all those doctors who prescribe epi-pens to patients are wrong huh? 

Here is a little insight into our thought process. A few years ago Epi was ALS only and Anaphylaxis was an ALS call. In Spokane a 9 year old boy came into contact with a peanut during lunch at school. The child went into Anaphylaxis. 911 was called and a BLS engine showed up. Unfortunately, EPI was not a BLS drug and they had to stand by for ALS. By the time ALS showed up the child was dead. Our statewide protocols were changed after that to allow Anaphylaxis to be treated at the BLS level with Epi-pen and rapid transport. 

Many counties around here allow the Basics to use a Combitube or King. While not the same as an advanced airway, it is more than just doing nothing. 

In my case, when I gave the Epi pen the effects were amazing. That stuff does work and it works fast. I would surmise that very few anaphylaxis patients require an advanced airway. Something else is ongoing if that is required. 

BLS and ALS both have their role and knowing it is important. However, if your a BLS provider and you cannot at least start treatment of a critically ill patient then something is seriously wrong. Even on ALS calls, there are things I can be doing for the patient to improve their outcomes. 

For all the ALS level patients that we transport in our BLS units we have very good patient outcomes. It works for us. I like Paramedics, I respect them and what they have gone through to earn the medic title. I have enough respect for them and their skill set to make sure I understand the ALS indicators and not waste their time. In the city of seattle, if you ride in a Medic unit you are REALLY, REALLY, REALLY sick.


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## VFlutter (Jan 5, 2013)

leoemt said:


> Have you ever seen Anaphylaxis in the field? Do you know the physiological process behind it?
> 
> *Do you?
> 
> In the city of seattle, if you ride in a Medic unit you are REALLY, REALLY, REALLY sick.



Is that really something to brag about? Is a system pushing the limit of safe and prudent care by turfing everything to BLS and having under-qualified providers simply hall *** to the ER really acceptable?


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## NYMedic828 (Jan 5, 2013)

leoemt said:


> Do you know the physiological process behind it?



Careful with that one... It's pretty complicated...

Also I believe the proper terminology would be pathophysiologic. Physiologic would imply normal body function and not a disease process.


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## DrParasite (Jan 5, 2013)

difference between an ALS call and a BLS call?   on an ALS call, the assessment usually involves a cardiac monitor and a BGL check (which is now BLS in some states).

I'm not a medic, nor am I an ALS provider.  But I'm pretty good at telling what patients need advanced and what patients are stable.  Those people who are sick and dying need ALS care, usually to treat an acutely life threatening emergency or a chronic medical condition that has gotten to the point that it is not acutely life threatening.  

You don't need to be a medic to know sick or not sick.  Have I made mistakes?  sure.  Have paramedics made mistakes?  sure  Have I been on a BLS truck, and seen paramedics turf patients that are either sick/in need of ALS or deteriorate during transport?  you betcha.  

I really pity all the paramedics out there who can't trust their BLS providers to do anything.  there is truly something wrong with your EMS system.  NJ might  have it's faults, but in every agency I have worked with that has ALS and BLS providers, if you are absolutely useless on a call, than you are usually advised to seek employment elsewhere.


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## the_negro_puppy (Jan 5, 2013)

Bullets said:


> "Thats not going to happen"
> 
> So i subjected my patient to pain while this Medic unit literally held analgesics  in their hands but wouldnt even try to get permission to administer it.



What a sick joke. Withholding analgesia for a fractured femur is barbaric. If you don;t give analgesia for a fractured femur, when do you give it? sigh


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## systemet (Jan 5, 2013)

DrParasite said:


> I'm not a medic, nor am I an ALS provider.  But I'm pretty good at telling what patients need advanced and what patients are stable.  Those people who are sick and dying need ALS care, usually to treat an acutely life threatening emergency or a chronic medical condition that has gotten to the point that it is not acutely life threatening.
> 
> You don't need to be a medic to know sick or not sick.  Have I made mistakes?  sure.  Have paramedics made mistakes?  sure  Have I been on a BLS truck, and seen paramedics turf patients that are either sick/in need of ALS or deteriorate during transport?  you betcha.



I recognise that you're a smart guy, but you need to also appreciate that not everyone acutely sick declares themselves in a clear manner. I'm sure we've both done lots of chest pain calls. Many of the guys I thought were dying turned out to have non cardiac etiologies, many had simple UA.  Some of the mildest chest pain or weak and dizzy all over old ladies have ended up being STEMIs.

Sometimes it's as important to recognise the limitations of our knowledge,  technology and ability to assess the patient in the field. Medic school taught me as much about  what I didn't know as it did anything else.



> I really pity all the paramedics out there who can't trust their BLS providers to do anything.  there is truly something wrong with your EMS system.



Me too. But, part of the responsibility as a paramedic is stepping in when the patient needs an advanced provider, and part of the responsibility as any level is knowing when a patient requires a higher level of care.

With respect.


----------



## Clare (Jan 5, 2013)

I don't think I really understand what you are discussing so perhaps my input will be a little off the mark.

Of course there is a difference between somebody at different practice levels can do; an Intensive Care Paramedic (ALS) can do far more than an Emergency Medical Technician (BLS) but that is because they have put in an extra four years at University to gain the knowledge and have the experience applying that knowledge.

As to who drives and who attends it really depends upon the patient; if the patient has some critical problem such as post-cardiac arrest, traumatic brain injury or whatever then the higher level Ambulance Officer will be in the back with them; however this is often not the case as stable patients build experience so the ICP will drive.


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## systemet (Jan 5, 2013)

leoemt said:


> In my case, when I gave the Epi pen the effects were amazing. That stuff does work and it works fast. I would surmise that very few anaphylaxis patients require an advanced airway. Something else is ongoing if that is required.



Are you extrapolating from n=1?  You're aware that even with aggressive ED and ICU care, anaphylaxis still kills people, right?  Why does it surprise you that an anaphylactic patient might require intubation? Do you understand that a symptom of anaphylaxis may be rapid laryngedema leading to total airway obstruction?

Have you considered that an anaphylactic reaction may interact with other pathology - e.g. anaphylaxis in the asthmatic patient?  

Are you aware of the myriad different presentations of anaphylaxis that may occur?  Have you encountered patients that present with massive angioedema, but little bronchospasm, hypotension, or GI symptoms?  Have you seen the patient who has profound hypotension, emesis, diarrhea, but no uriticaria or pruritis?  Have you met the patient whose first presenting symptom is severe bronchospasm leading to respiratory failure?  All of these guys are out there.

An epi pen for EMTs is not a bad idea.  But it doesn't mean that ALS care is no longer necessary, or that you're equipped to deal with every anaphylaxis patient coming your way.


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## VFlutter (Jan 5, 2013)

systemet said:


> Do you understand that a symptom of anaphylaxis may be rapid laryngedema leading to total airway obstruction?




It's all good they got combitubes h34r: I bet they work great with bronchospasms and intact gag reflexes


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## NYMedic828 (Jan 5, 2013)

Should probably make a new topic but here's a side question

In the case of severe laryngoedema, how much swelling occurs to the lower airways?

Obviously keeping a patent opening to the glottis/trachea is vital but what goes on beyond that? Is it only spasm/mild inflammation or can complete blockage occur in the bronchi as well?


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## abckidsmom (Jan 5, 2013)

NYMedic828 said:


> Should probably make a new topic but here's a side question
> 
> In the case of severe laryngoedema, how much swelling occurs to the lower airways?
> 
> Obviously keeping a patent opening to the glottis/trachea is vital but what goes on beyond that? Is it only spasm/mild inflammation or can complete blockage occur in the bronchi as well?



Yep, that's a total threadjack.  Go ahead and ask your question in a new thread, anaphylaxis is a great topic for us to discuss.  It's one of the true life-threatening emergencies we face.


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## AnthonyTheEmt (Jan 5, 2013)

abckidsmom said:


> Yep, that's a total threadjack.  Go ahead and ask your question in a new thread, anaphylaxis is a great topic for us to discuss.  It's one of the true life-threatening emergencies we face.



My thoughts exactly. In the system I work in, echo level is the highest level call and to my knowledge there's only 2-3 things that get an echo response
1. Cardiac arrest
2. Anaphylaxis
Not sure after that


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## NYMedic828 (Jan 5, 2013)

AnthonyTheEmt said:


> My thoughts exactly. In the system I work in, echo level is the highest level call and to my knowledge there's only 2-3 things that get an echo response
> 1. Cardiac arrest
> 2. Anaphylaxis
> Not sure after that



Really? theres nothing on par with anaphylaxis? That is poor system design.


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## AnthonyTheEmt (Jan 5, 2013)

firefite said:


> As the poster said he/she is close to many hospitals. Transporting to a hospital is a better idea then waiting for ALS if the hospital is closer.



I dont know how things work where youre at (not at meant to sound judgmental, because its not), but the county I work in, not everywhere is a STEMI or CVA center. If you rush a stroke pt to the nearest hospital because ALS is too far out, youre actually hurting your patient instead of helping them. I have made this mistake unfortunately and luckily it didnt come back to bite me in the butt


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## DesertMedic66 (Jan 5, 2013)

AnthonyTheEmt said:


> I dont know how things work where youre at (not at meant to sound judgmental, because its not), but the county I work in, not everywhere is a STEMI or CVA center. If you rush a stroke pt to the nearest hospital because ALS is too far out, youre actually hurting your patient instead of helping them. I have made this mistake unfortunately and luckily it didnt come back to bite me in the butt



My area is not an issue. Out of 3 hospitals all 3 of them are STEMI and Stroke centers. 1 is a trauma center and 2 are OB centers. 

Not quite sure how it works in other areas but all EMTs and Medics know what hospitals can do what. 

Call dispatch and get an ETA for ALS and know your ETA to the hospital. If ALS is the same ETA or longer then your transport time to the appropriate hospital then BLS transports. 

ALS isn't able to do much more for a stroke patient than BLS can (12-lead, IV, BGL (pretty much a BLS skill in my area), and blood draws is about it for my area).


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## AnthonyTheEmt (Jan 5, 2013)

firefite said:


> My area is not an issue. Out of 3 hospitals all 3 of them are STEMI and Stroke centers. 1 is a trauma center and 2 are OB centers.
> 
> Not quite sure how it works in other areas but all EMTs and Medics know what hospitals can do what.
> 
> ...



See, youre very lucky then. In my county,  I worked BLS for 3 1/2 years before working as a medic. I can say from experience, as horrible as this sounds, alot of the EMT's who work for private companies dont know which hospital is a CVA center or STEMI center, or trauma center. Its really sad, because the companies do not force their employees to learn hospital specialties, much less protocols. And patients suffer for it. You get some BLS crew who thinks they are being heroes because they bring in the hot stroke to the nearest hospital, which may or may not be a stroke center, only to be told "good job jackass, now we have to transfer them before the 4 hour window is over", whereas if they had transferred that to an ALS crew, the ALS crew wouldve known to take them to the appropriate hospital. Also, I work in California, which lives up the reputation of neutering the BLS scope and things like Pulse ox and BGL (oh gosh, that is waaaaay too complicated for knucklehead EMT's :/ ) are technically outside of the BLS scope


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## Aidey (Jan 5, 2013)

It isn't always that simple. What if it isn't a CVA, it is Todd's paralysis post seizure, and the pt starts seizing again? Or has a seizure because of the neurological insult? If the pt meets certain criteria and has certain interventions, like bilateral IVs, some hospitals will bypass the ED and go straight to CT. There is always the potential airway issue too. You get the idea.


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## JPINFV (Jan 5, 2013)

I wonder how many "CVAs" encountered by EMTs are hypoglycemic patients, where if they called for paramedics when right down the street from the hospital they'd be told "Good job delaying care [and getting us out of our lazy boy]... jackass." 

Of course that's why I'm a fan of using the "can we get an updated blood glucose level? You know... for the hospital..." line on SNFs.


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## DesertMedic66 (Jan 6, 2013)

Aidey said:


> It isn't always that simple. What if it isn't a CVA, it is Todd's paralysis post seizure, and the pt starts seizing again? Or has a seizure because of the neurological insult? If the pt meets certain criteria and has certain interventions, like bilateral IVs, some hospitals will bypass the ED and go straight to CT. There is always the potential airway issue too. You get the idea.



But once again this comes down to the time issue. Now you have to wait for ALS to get on scene, assess the patient, start treatments/interventions, and then transport. If the hospital is closer then the nearest ALS unit why wait for ALS? Transport the patient to definitive care at the ER. 

Hospital and ALS unit are 20 minutes away. Is it better to transport the patient BLS to the hospital (20 minutes total) or wait for the ALS unit to get on scene (20 minutes) + the time to assess the patient (5 minutes) + the transport time to the hospital (20 minutes). So 20 minutes to the hospital vs 45 minutes to the hospital.


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## abckidsmom (Jan 6, 2013)

firefite said:


> But once again this comes down to the time issue. Now you have to wait for ALS to get on scene, assess the patient, start treatments/interventions, and then transport. If the hospital is closer then the nearest ALS unit why wait for ALS? Transport the patient to definitive care at the ER.
> 
> Hospital and ALS unit are 20 minutes away. Is it better to transport the patient BLS to the hospital (20 minutes total) or wait for the ALS unit to get on scene (20 minutes) + the time to assess the patient (5 minutes) + the transport time to the hospital (20 minutes). So 20 minutes to the hospital vs 45 minutes to the hospital.



Some might advocate for sending ALS immediately on dispatch.  Sounds like most of the issues in this discussion come not from provider deficiency but system design issues.


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## Aidey (Jan 6, 2013)

I agree. ALS should be dispatched to these calls from the get go.


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## DesertMedic66 (Jan 6, 2013)

abckidsmom said:


> Some might advocate for sending ALS immediately on dispatch.  Sounds like most of the issues in this discussion come not from provider deficiency but system design issues.



Ooh I know about system design issues, any 911 call (I mean any at all) get at least one fire engine responding with 1-4 medics in board, plus an ambulance with 1–2 medics on board. Good old California :rofl:


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## AnthonyTheEmt (Jan 6, 2013)

JPINFV said:


> I wonder how many "CVAs" encountered by EMTs are hypoglycemic patients, where if they called for paramedics when right down the street from the hospital they'd be told "Good job delaying care [and getting us out of our lazy boy]... jackass."
> 
> Of course that's why I'm a fan of using the "can we get an updated blood glucose level? You know... for the hospital..." line on SNFs.



When I was working as an EMT, I actually got yelled at by a nurse at a SNF for asking for a BS on an altered patient, and given a verbal warning by my sup for "insulting the nurse by asking for a blood sugar on a non-diabetic patient". That is the kind of idiocy at these BLS companies. So that asking for BGL isnt always an option


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## abckidsmom (Jan 6, 2013)

firefite said:


> Ooh I know about system design issues, any 911 call (I mean any at all) get at least one fire engine responding with 1-4 medics in board, plus an ambulance with 1–2 medics on board. Good old California :rofl:



Somewhere between CA and NJ is a near-perfect system that staffs a mix of ALS and BLS units, with a medic or two in a fly car just for fun. The dispatchers are all smart and able to use their judgement to override CAD-driven upgrades to obvious BLS calls (not breathing normally leg pain) and lollipops and rainbows abound. 

Somewhere over the rainbow.


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## JDub (Jan 6, 2013)

abckidsmom said:


> I ride with BLS partners. Say we get a psych call. BLS right? Say my inexperienced partner says the wrong thing, puts his foot in his mouth, does nothing good for the patient, and magnifies the problem, whatever it is.
> 
> I have about 20 times the experience, and 50 times the education in dealing with psych problems.
> 
> ...



Aren't you making a lot of assumptions? You are a educated, experienced paramedic. Are all ALS providers that way? Unfortunately they are not. For every person like you, there is some fresh out of a degree mill paramedic with a god complex that thinks they can do no wrong.

Likewise although there are some inexperienced ignorant EMTs, there are also very experienced and knowledgeable EMTs that for whatever reason have not gotten their paramedic certification.

-----------

As far as drawing the ALS/BLS line, I think that is up to each crew individually. Obviously if the call requires ALS interventions then it will be an ALS call. However I don't think calls should be made ALS just because of a chief complaint. 

For example in my system, a nausea/vomiting patient is supposed to be ALS. The reasoning is that a medic can start an IV, give fluids, give anti-emetics and so on. However, a lot of medics will simply choose to take the call and BLS it themselves. Was the patient really helped at all by having paramedic ride that call? Well of course not.

With that being said, that also is sometimes an issue of medics being lazy. But that is a different discussion...


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## VFlutter (Jan 6, 2013)

JDub said:


> there are also very experienced and knowledgeable EMTs that for whatever reason have not gotten their paramedic certification.



Regardless of how experienced or knowledgeable an EMT is they are very limited in their scope and ability to intervene in true medical emergencies. Allowing even the most experienced BLS crew to take calls that should be ALS is unacceptable and unsafe. I consider myself fairly intelligent and competent medical provider but I still would not attempt to take on a (Insert whatever ALS patient you claim you can take as BLS) functioning as a Basic, its just poor patient care.


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## firecoins (Jan 6, 2013)

Paperwork


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## emt11 (Jan 6, 2013)

And on that note is where the fun of my state being an EMT-I/AEMT is considered BLS and only a medic is ALS. 

And on the note of epi, as an AEMT, I dont have epi pens on my truck(then again, I don't recall ever hearing of any trucks around that carry epi pens), I have epi 1:1 vials(you know, the little glass ones that like to cut the s**t out of your finger if you dont do it right) that I would have to draw up to do an IM injection.


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## EpiEMS (Jan 6, 2013)

Chase said:


> Regardless of how experienced or knowledgeable an EMT is they are very limited in their scope and ability to intervene in true medical emergencies. Allowing even the most experienced BLS crew to take calls that should be ALS is unacceptable and unsafe. I consider myself fairly intelligent and competent medical provider but I still would not attempt to take on a (Insert whatever ALS patient you claim you can take as BLS) functioning as a Basic, its just poor patient care.



+1. While I don't like to have to ask a medic to take a call in that "could be BLS", I have no qualms about doing it if I feel the patient's condition warrants it. The patients come first, after all.


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## Tigger (Jan 6, 2013)

I don't understand how BLS providers can really claim that they can make the "sick or not sick" determination on their own with an acceptable degree of accuracy. 

Obviously there are EMTs out there that have more education than just their initial course and mandated CE hours (I would like to think I am one of them). But clearly, such EMTs are the exception and not the rule. So on what grounds are BLS providers making this determination? Some sort of spidey sense? Surely it was not was taught in the initial course, as that curriculum puts everyone and their sister in the "sick" category.

Some will say experience, which is in no way, shape, or form commiserate to actual education. Saying that you have had thousands of patients contacts somehow makes you capable of figuring out who is sick and who not is bunk. Just because the patient made it the hospital in a condition unchanged as to what you found them in does not mean that they were "not sick." If you run all these calls, there is no way you can go back and figure out from the hospital what the patient's condition was, _so how do you know you are ever correct?_

It seems to me that many systems are set up backwards. Right now our first line providers are sent out with minimal education and are expected to know when they need help. From a _purely patient driven perspective_, wouldn't in make a lot more sense to *send the providers that actually have some real education in patient assessment first, and if their assessment so warrants it, send them with those less educated?*

But then again, what difference does it make? If we overtriage everyone the hospital will just sort it all out and then they will certainly look at us as equals in healthcare. Right?


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## DrParasite (Jan 6, 2013)

systemet said:


> I recognise that you're a smart guy, but you need to also appreciate that not everyone acutely sick declares themselves in a clear manner.


absolutely!!! like the stubbed toe might actually be an MI.  or the drug seeker might have recently had a silent MI.  or the abdominal pain on the bus is actually an MI (actually had a female patient like this, paramedics assessed and released her to BLS, monitor and everything, bloodwork in the ER showed she had an MI).  and the person who calls 911 because it burns when he pees? yeah, that person might actually be dying.  but if it walks like a duck, talks like a duck, and quacks like a duck, i'm not going to be feeding it peanuts.


systemet said:


> I'm sure we've both done lots of chest pain calls. Many of the guys I thought were dying turned out to have non cardiac etiologies, many had simple UA.  Some of the mildest chest pain or weak and dizzy all over old ladies have ended up being STEMIs.


ditto, and ditto.  but how many 23 years olds with severe chest pain turned out to be cardiac in nature?  I can think of one, and she had a history of an implanted AED.



systemet said:


> Sometimes it's as important to recognise the limitations of our knowledge,  technology and ability to assess the patient in the field. Medic school taught me as much about  what I didn't know as it did anything else.


yep.  and if you go onto med school, you will be able to recognize more stuff, use more technology, and assess better (the latter is what I have been told).  and I have yet to hear a medic ask about family history when it comes to a chest pain call, but most docs do.





systemet said:


> Me too. But, part of the responsibility as a paramedic is stepping in when the patient needs an advanced provider, and part of the responsibility as any level is knowing when a patient requires a higher level of care.


and part of being a competent provider (not even good EMT, just competent) is to know when to call for help, or for a more senior or educated person because your patient needs more care than you can provide.





JPINFV said:


> I wonder how many "CVAs" encountered by EMTs are hypoglycemic patients, where if they called for paramedics when right down the street from the hospital they'd be told "Good job delaying care [and getting us out of our lazy boy]... jackass."


I've had two in my career.  the first time the medic did call me a jackass, because the patient was loaded and in the truck, full CVA symptoms, and the paramedic checked the BGL as we pulled into the stroke center parking lot.  the second time it was a "ahhh, that's what it is, take him out of the truck, put him back into bed, and we will walk him up and raise his sugar up and he will return to normal."


abckidsmom said:


> Some might advocate for sending ALS immediately on dispatch.  Sounds like most of the issues in this discussion come not from provider deficiency but system design issues.


Depending on criteria, they typically are.  I'm not a big fan of ALS on CVA calls (esp if BLS is able to check BGLs) where there isn't an airway compromise, because BLS can do the stare of life just as good as the ALS can (and our BLS crews can activate the stroke team on their own if needed).





abckidsmom said:


> Somewhere between CA and NJ is a near-perfect system that staffs a mix of ALS and BLS units, with a medic or two in a fly car just for fun. The dispatchers are all smart and able to use their judgement to override CAD-driven upgrades to obvious BLS calls (not breathing normally leg pain) and lollipops and rainbows abound.
> 
> Somewhere over the rainbow.


I'd like to invite you to Newark, Irvington, and Jersey City.  Those cities use a system that you describe (with the exception of the automatic dispatch upgrades), and you can judge for yourself how it works.  


Chase said:


> Regardless of how experienced or knowledgeable an EMT is they are very limited in their scope and ability to intervene in true medical emergencies. Allowing even the most experienced BLS crew to take calls that should be ALS is unacceptable and unsafe. I consider myself fairly intelligent and competent medical provider but I still would not attempt to take on a (Insert whatever ALS patient you claim you can take as BLS) functioning as a Basic, its just poor patient care.


While I agree with you in theory, the question becomes what you define as an ALS call?  if a CVA patient has a normal BGL and no airway issues, is it ALS?  what is ALS going to do any differently than BLS?   or a runny nose?  or the flu (with normal vitals)?  or a person who drank too much?  how about neck and back pain from an MVA? Some will say BLS, some will say ALS. it's all how your system is set up.


----------



## DrParasite (Jan 6, 2013)

Tigger said:


> I don't understand how BLS providers can really claim that they can make the "sick or not sick" determination on their own with an acceptable degree of accuracy.


well..... how do ALS providers make that claim?  do you think doctors and nurses have the same problem understanding how ALS providers make that claim?





Tigger said:


> Obviously there are EMTs out there that have more education than just their initial course and mandated CE hours (I would like to think I am one of them). But clearly, such EMTs are the exception and not the rule. So on what grounds are BLS providers making this determination? Some sort of spidey sense? Surely it was not was taught in the initial course, as that curriculum puts everyone and their sister in the "sick" category.


same question, how do paramedics judge sick vs not sick? hopefully they have something more reliable than spidey sense (although my spidey sense has alerted me to a sick patient or two).





Tigger said:


> Some will say experience, which is in no way, shape, or form commiserate to actual education. Saying that you have had thousands of patients contacts somehow makes you capable of figuring out who is sick and who not is bunk. Just because the patient made it the hospital in a condition unchanged as to what you found them in does not mean that they were "not sick." If you run all these calls, there is no way you can go back and figure out from the hospital what the patient's condition was, _so how do you know you are ever correct?_


actually, while that is one of the sick vs not sick gauges, add "what would ALS do that would have a positive impact on these patients" and is the delay of definitive care beneficial to the patient?  

and we often return to the hospitals (on subsequent visits with new patients), and can get follows up.  if we screw up, a complaint is given to our clinical coordinator.  or, depending on how well the staff knows you, the ER doctor might just pull you aside and say "hey I need to have a word with you."


Tigger said:


> It seems to me that many systems are set up backwards. Right now our first line providers are sent out with minimal education and are expected to know when they need help. From a _purely patient driven perspective_, wouldn't in make a lot more sense to *send the providers that actually have some real education in patient assessment first, and if their assessment so warrants it, send them with those less education?*actually, if you send out the highly trained people (paramedics or nurse, doctors, etc), and all they see is minor patient, studies have shown that their skills will deteriorate, because they don't see many acutely sick patients that require interventions requiring their care.  Just look at California and their intubation numbers.  BTW, full time Jersey medics typically intubate patients at least once a week. and that's state wide.
> 
> 
> Tigger said:
> ...


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## Veneficus (Jan 6, 2013)

Tigger said:


> It seems to me that many systems are set up backwards. Right now our first line providers are sent out with minimal education and are expected to know when they need help. From a _purely patient driven perspective_, wouldn't in make a lot more sense to *send the providers that actually have some real education in patient assessment first, and if their assessment so warrants it, send them with those less education?*



This is definately the smartest thing said in this thread.

After reading through this thread, I would just like to point some things out.

In the life threatening emergencies described earlier, BLS transport is the proper thing to do. The very purpose of BLS is simple but effective life saving techniques. airway obstruction, cardiac arrest, epi pens, etc.

Trauma is the same way, it has been determined by a handful of studies that show trauma patients are better served by BLS transport. The reasons are multifactorial. 1. there is no delay in transport for "advanced procedures." 2. Basics do not provide procedures that actually harm. Like large fluid boluses, 5intubation attempts on scene, or a failed intubation. 

Let's not pretend a majority of paramedics can intubate, or intubate effectively enough to allow wide spread use of RSI to manage patients who require it. 

Let's not pretend many places have adopted modern trauma techniques and are not still administering large fluid boluses, which in an open circuit increases bleeding and decreases hemostasis. In a closed circuit increases cerebral edema.

In this day, no matter how good the providers on this forum, they are a minority, and ALS does not always help the patient.

The new guy...

NO matter how good any of us are or think we are, we cannot see every patient. The only way new people become experienced old people is to let them take patients and make mistakes. Otherwise, they become inexperienced senior people one day. It is a very difficult thing to do to give up the reins when we know we could do better. Unfortunately, we have to.

Sick and not sick...

I always laugh when I hear basics claim they know what it looks like. I laugh almost as hard when medics claim to. Given the amount of underdiagnosis or misdiagnosis of life threatening conditions by physicians, and the fact that no US EMS curriculum yet contains education on who requires hospital admission or to what unit, or even by what specialty, please, you are not kidding anyone but yourself. (Off hand I know that sepsis is undiagnosed in 40% of the neonatal population. An even greater number I am told in the geriatric population.)

Furthermore, the EMS curriculum teaches about the most common acute disease presentations as they were in the 1960s-1980s, certainly not all of them. Not even a majority.

What is worse, they teach about the late phases, which means you don't know what the early phase may look like. (this should be a very scary feeling) 

The idea Basics can decide "sick/not sick" also doesn't account for a majority of ED patients who need medical care but do not need emergency care.

Let me demonstrate, you were all told that severe trauma requires a surgeon. Some of you may even know what some of those procedures are. How many non-physicians here can tell me the indications for various emergency surgeries in trauma patients?

I'll even give you a hint, "bleeding you cannot see" is not one of them. Low grade liver and splenic lacs can be managed without any surgical procedure at all.

When even a nonmedical provider can look at a patient and decide they are F****d up, an EMT being able to do it is not expertise.


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## usalsfyre (Jan 6, 2013)

Veneficus said:


> *What is worse, they teach about the late phases, which means you don't know what the early phase may look like. (this should be a very scary feeling)*


(bolding, underlining mine)

Huge, huge point here. Most medics don't really know "sick" till it slaps them in the face. I didn't learn early presentation of "sick" until I worked in an ED for a while. The number of patients I wrote of as "BS" that ended up as ICU and tele admissions scared the crap out of me.


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## DrParasite (Jan 6, 2013)

Veneficus said:


> I always laugh when I hear basics claim they know what it looks like. I laugh almost as hard when medics claim to.


and yet, we still want to send medics to all calls.





Veneficus said:


> Given the amount of underdiagnosis or misdiagnosis of life threatening conditions by physicians, and the fact that no US EMS curriculum yet contains education on who requires hospital admission or to what unit, or even by what specialty, please, you are not kidding anyone but yourself. (Off hand I know that sepsis is undiagnosed in 40% of the neonatal population. An even greater number I am told in the geriatric population.)


so if an all educated doctor misdiagnoses or underdiagnosis, patient, what hope is there for EMS personnel?





Veneficus said:


> Furthermore, the EMS curriculum teaches about the most common acute disease presentations as they were in the 1960s-1980s, certainly not all of them. Not even a majority.
> 
> What is worse, they teach about the late phases, which means you don't know what the early phase may look like. (this should be a very scary feeling)


that I didn't know, and that is a scary thought.  but I would still blame the education system, not the providers themselves.  change starts with the initial schooling, so when the newbies become oldies in 10 years, you have overhauled the system.


Veneficus said:


> The idea Basics can decide "sick/not sick" also doesn't account for a majority of ED patients who need medical care but do not need emergency care.
> ...
> When even a nonmedical provider can look at a patient and decide they are F****d up, an EMT being able to do it is not expertise.


please elaborate on your first statement.  and as for your second, yes, I agree (we have cops saying the patient is sick all the time), but the EMT (and paramedic) should have a little deeper understanding of why they are sick.


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## systemet (Jan 6, 2013)

DrParasite said:


> or the abdominal pain on the bus is actually an MI (actually had a female patient like this, paramedics assessed and released her to BLS, monitor and everything, bloodwork in the ER showed she had an MI).



This is fairly common.



> but how many 23 years olds with severe chest pain turned out to be cardiac in nature?  I can think of one, and she had a history of an implanted AED.



Have these 23 year olds been doing cocaine?  Just something to think about.  In my system we have thrombolysed patients in their 20's, but this is, as you said, extremely rare.



> yep.  and if you go onto med school, you will be able to recognize more stuff, use more technology, and assess better (the latter is what I have been told).  and I have yet to hear a medic ask about family history when it comes to a chest pain call, but most docs do.



I do, because I feel like when I hand the patient over, I should have done as thorough an H&P as I'm capable of.  That being said, the familial risk factors are more useful when you're stratifying the patient for different levels of intervention or follow-up, which is something we don't really do as paramedics.

I absolutely agree that physicians are educated far beyond the paramedic level, and recognise that there are some spectacular gaps in my own knowledge.  Over the years I've been working on filling some of them.  But the reality is, there's a greater gap between the education of an average paramedic and an average physician than there is between an average EMT and an average paramedic.

I think we're actually agreeing here, to some degree.  The other thing I'd add, is there's no reason why an EMT shouldn't be able to education themselves beyond the limits of what they learned in a short EMT program and become more knowledgeable about patho, physio, pharm, EKG, etc. than me.  Generally, going to paramedic school is going to be an easier way to attain understanding of a basic body of knowledge than trying to self-educate.


----------



## Veneficus (Jan 6, 2013)

DrParasite said:


> and yet, we still want to send medics to all calls.



In theory, the more educated your provider, the better chance you have of not misdiagnosis or underdiagnosing. 

I think the benefit of sending a medic to the call first and then downgrading if the patient can be and is a superior system design. 

Along the same lines, I have no problem with a medic responding to a call, like a CVA, deciding there is nothing they can do for them BLS cannot and still turfing them.

With the advances in basic science components in the original medic curriculum, I think that the amount of mis or non dx will go down. 



DrParasite said:


> so if an all educated doctor misdiagnoses or underdiagnosis, patient, what hope is there for EMS personnel?.



I think the hope is in the technique. Most doctors, and it is really an individual philosophy, always take the approach of treating horses before zebras. Which is not bad medicine because they will be right more often than not. 

However, after many years of practicing this way, they stop looking for the zebras, and consequently never find them. It is my experience that the same thing happens to these patients as does EMS pattients. The docs figure it out when anyone could tell you the patient is messed up. 

Those that have worked with me can attest, I am a zebra hunter. I look for them and I find them. But I always consider the lesser common pathologies. I believe it is better to not miss the outliers and to be as accurate as is possible with reasonable effort in the initial Dx.

Treating by numbers has a level of effectiveness, that is why PAs and NPs can post such good results compared to docs doing the exact same thing. 

But when it is you or your loved ones, do you want them to be a number or diagnosed as an individual?

I will concede, most of the time they will fall into the most common category, but when they don't how long it takes to discover that could make a major difference.

Any EMS provider can adopt either of these philosophies in their practice. The individual approach to Dx can also be taught in EMS education.   



DrParasite said:


> that I didn't know, and that is a scary thought.  but I would still blame the education system, not the providers themselves.



I do blame the system. Unfortunately, in order to change the system is to point out the faults. That means dispelling the illusional superiority or ignorance and not only offering a better way, but advocating for it.



DrParasite said:


> change starts with the initial schooling, so when the newbies become oldies in 10 years, you have overhauled the system.



Which is why I point it out here. When the newbies see they don't know it all, they are the most likely to further educate themselves. It is easier to teach a new dog new tricks than get an old one to change theirs.



DrParasite said:


> please elaborate on your first statement.



There have been several studies done, I am just to lazy to hunt them down, (You have to give me a break, I read on average 6-10 studies a day, I don't remember where they all are and I don't get paid to spend time here tracking them down)

As well, anyone who spends any time in an ED can tell you they see a lot of patients who get admitted for non lifethreatening healthcare.

Furthermore, anyone who works on an ambulance, especially in countries like AU, NZ, etc, can tell you a patient may be better served by another healthcare resource than an ED or ICU.

The fact is in the US, the ED, and by extension EMS, is the primary entrance to the healthcare system. (whether or not this is right is a matter of debate, but it doesn't change what is) People who need healthcare but not acute care, engage such as their entrance. 

Does every abdominal pain require emergency surgery?
Of course not.

Does every pneumonia patient need to be admitted to an ICU?
Of course not. 

But they do need to be diagnosed and treated. 

How often has a family member or non EMS friend asked you if they need stitches for a cut?

Certain wounds benefit from suturing, and like all medicine, earlier treatment is better than later.

These are examples of people who need medical care. They need Dx and benefit from treatment. But let's face it, they do not really need an emergency ambulance or ED. 

Moreover, the treatment they recieve in the ED may not help their condition at all, because all they are getting is a tempporizing measure for a chronic problem. When that runs its course, they will either be back to the ED for more temporizing, or they will have seen another medical provider who is managing their condition long term.


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## ZombieEMT (Jan 6, 2013)

*ALS by BLS*

I work in Cape May County in NJ and the issue that we see very often is not having a medic available when needed. Our area of the county only has two medic units (which is typically enough) but when crap hits the fan its kind of up to BLS to transport with out ALS. For that reason, there are many times at which we have a patient that meets ALS dispatch protocols but we recall to save the medic unit for high priority. Some calls meet ALS protocol but ALS does not do much more for the patient than what BLS will do.

Also, we never wait for a medic unit. We load and go and hope to meet in route.


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## RocketMedic (Jan 6, 2013)

Veneficus said:


> This is definately the smartest thing said in this thread.
> 
> After reading through this thread, I would just like to point some things out.
> 
> ...



Which is why I'll literally tell my patients who don't want to go "because you need to see someone with a lot more schoolin' than I have."


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## KingCountyMedic (Jan 9, 2013)

In Seattle & King County Washington any patient that gets an epi pen used on them is always going to get a Medic eval. As far as transport is concerned you will see BLS transport a majority of these patients as most are not complicated and have a documented history of same/scrip for their own epi pen etc. As far as BLS transporting truly sick people with airway issues or serious trauma or any other of the horror stories you hear on here I can tell you it doesn't happen. If I put a sick person in an ambualnce that should have been in my truck under my care I am going to hear about it from the Doctor at the recieving hospital. If it is really bad he will call my Medical Director and if he gets involved then I am in real, real, BIG TIME trouble. Most services do not have any where near the level of Physician involvment in their programs compared to ours. I know because I spent close to 20 years working in Washington State in Pierce, Thurston, and Kitsap County. I spent the majority of my life working Private Ambulance and have been an EMT getting patients from Seattle and King County Medics. No system is perfect. Not even ours! We welcome riders all the time. I know a lot of the people that really trash Seattle & King County and I know for a fact that the majority of people that bad mouth us on here and other forums have not been able to get hired with us. There are also a few fellas that didn't make probation after completing school and so they have big chips as well. I won't get into a public debate with anyone on here but if you have interest or questions about riding send me a message.


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## usalsfyre (Jan 9, 2013)

KingCountyMedic said:


> I know a lot of the people that really trash Seattle & King County and I know for a fact that the majority of people that bad mouth us on here and other forums have not been able to get hired with us. There are also a few fellas that didn't make probation after completing school and so they have big chips as well. I won't get into a public debate with anyone on here but if you have interest or questions about riding send me a message.




The old "they're just jealous" defense, real original. My criticism is not over life threats, its over the fact that the KCM1 and many other chase car based systems don't seem to think things like analgesics and anti-emetics are important. As a previous patient and a current provider and administrator that irritates me to no end. Paramedics don't "save lives". What they really do is ease pain and suffering. When you can come up with a better constructed argument for that than "its a bunch of whining scrubs" come back to me.  

For the record I've not nor do I really ever see my self moving to Seattle to work on a truck. So that one doesn't work here.


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## Tigger (Jan 10, 2013)

KingCountyMedic said:


> I know a lot of the people that really trash Seattle & King County and I know for a fact that the majority of people that bad mouth us on here and other forums have not been able to get hired with us. There are also a few fellas that didn't make probation after completing school and so they have big chips as well. I won't get into a public debate with anyone on here but if you have interest or questions about riding send me a message.



How exactly do you "know for a fact" that most people on this site with criticisms of your agency have not been able to get hired?


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## whitelcpl0311 (Jan 11, 2013)

Hey guys, just stumbled across this site. I'm an EMT-B student in RI and I think I can add to how bad it sucks for the patient to have the person that is taking care of them be way in over their head as far as training/experience. (Just starting out EMT-B training, looking to apply to PA school when i finish my B.S. in biology in 2 years)

I was a Marine Corps Rifleman in Afghanistan in 2009, certified as a "combat lifesaver." While this is a good course, it is only 3 weeks long. On a patrol, both our corpsman (medics) became incapacitated by an IED (1 dead, 1 wounded with shrapnel to the eyes.) We also had 4 marines down, 2 dead, 2 severely wounded. So I'm this 20 year old Rifleman (my job was to kill people not save them), with a small medpack containing, H bandages, gauze, quickclot, and some mobic+ acetaminophen. The first guy I get to has an arterial bleed on his neck, which somehow i managed to stop by applying pressure and alot of gauze (how this happened I really dont know, i was worried i was pushing too hard on his neck). But I heard a gurgling sound, which I thought indicated a sucking chest wound (from my short training). So I'm getting ready with a large gauge needle to go in between this guys ribs (tension pneumo thorax i think?) Turns out, his windpipe was punctured and thats where the sound was coming from, so i refrained (thank god). I literally was winging his medical care... unfortunately I had no choice... we were a 30 min helicopter ride from the nearest base. (Somehow The guy did end up making it)


Sorry for rambling but I was just trying to point out how bad it sucks to be completely unqualified for taking care of a patient, and having no other choice. Complete Despair. Anyways, I'm paying CAREFUL attention in my EMT-B class as to not get that feeling of "Oh **** i have no idea what to do" ever again. 

Still not sure of how my local EMS system works... but i certainly would not feel comfortable riding around with just a new fellow basic. 

This site looks pretty cool, and I look forward to contributing to this community!Also I'd like to thank everyone on this site for what they do, fire/EMS/Police truly do not get the appreciation they deserve!


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## NomadicMedic (Jan 11, 2013)

Tigger said:


> How exactly do you "know for a fact" that most people on this site with criticisms of your agency have not been able to get hired?



I am also curious about this.


----------



## NYMedic828 (Jan 11, 2013)

KingCountyMedic said:


> In Seattle & King County Washington any patient that gets an epi pen used on them is always going to get a Medic eval. As far as transport is concerned you will see BLS transport a majority of these patients as most are not complicated and have a documented history of same/scrip for their own epi pen etc. As far as BLS transporting truly sick people with airway issues or serious trauma or any other of the horror stories you hear on here I can tell you it doesn't happen. If I put a sick person in an ambualnce that should have been in my truck under my care I am going to hear about it from the Doctor at the recieving hospital. If it is really bad he will call my Medical Director and if he gets involved then I am in real, real, BIG TIME trouble. Most services do not have any where near the level of Physician involvment in their programs compared to ours. I know because I spent close to 20 years working in Washington State in Pierce, Thurston, and Kitsap County. I spent the majority of my life working Private Ambulance and have been an EMT getting patients from Seattle and King County Medics. No system is perfect. Not even ours! We welcome riders all the time. I know a lot of the people that really trash Seattle & King County and I know for a fact that the majority of people that bad mouth us on here and other forums have not been able to get hired with us. There are also a few fellas that didn't make probation after completing school and so they have big chips as well. I won't get into a public debate with anyone on here but if you have interest or questions about riding send me a message.



Sure do know how to make friends in a hurry.


----------



## Sandog (Jan 11, 2013)

JPINFV said:


> 1. When talking about specific fields, you have to be specific to that field. Someone who has a PhD in Womyns Studies has more education than you, but that doesn't mean that you would let Dr. Womyn Studies take over for you when they have no EMS training.
> 
> 2. Basic science degrees provide an excellent jumping off point both for applied education (like paramedic training, and both for self an formal studying), however it does not, on its own, make an EMT able to practice as a paramedic.
> 
> ...



Okay, I think I see a misunderstanding here. When I hear "undereducated", my assumption is one lacking in education, i.e. high school dropout, or no post-secondary school. To me, "EMT-B are undereducated" sounds like a person aiming to get a GED one day.

As for my bio degree, I think my 2 semesters of molecular bio gives me a good understanding into the mechanics of human physiology.

And why do I mention my military background?  I think I was afforded a unique education which adds to my skill set and further removes me from the "undereducated" population.

Now, I do agree, when it comes to EMS, my skill set is lacking, but I am not "undereducated".


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## JPINFV (Jan 11, 2013)

Sandog said:


> Okay, I think I see a misunderstanding here. When I hear "undereducated", my assumption is one lacking in education, i.e. high school dropout, or no post-secondary school. To me, "EMT-B are undereducated" sounds like a person aiming to get a GED one day.



...and when it comes to medicine and health care the EMT curriculum is severely lacking, therefore making EMTs lacking in education in the field they are practicing in. 


> As for my bio degree, I think my 2 semesters of molecular bio gives me a good understanding into the mechanics of human physiology.



I have a BS in biology, a MS in biomedical science and am halfway through my 3rd year of medical school. Would you like me to run a cardiac arrest on you or a paramedic? Who has more education? In an applied science field, you have to be able to apply the science, not just think great thoughts. 




> And why do I mention my military background?  I think I was afforded a unique education which adds to my skill set and further removes me from the "undereducated" population.


 
6 years in the Navy doing, what? A military physician and the guy who watches the front gate of the base both can have 6 years experience, but you didn't qualify the experience as anything besides a number. Furthermore, different patient populations.


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## VFlutter (Jan 11, 2013)

Sandog said:


> And why do I mention my military background?  I think I was afforded a unique education which adds to my skill set and further removes me from the "undereducated" population.



Not necessarily directed at you but it irks me when military medics argue that experience doing advanced procedures in a combat setting validates them as a superior provider and somehow entitles them in the civilian world. Just because you were shown how to perform a surigcal cric, which is a relatively simple procedure, does not mean that you should be allowed to function at the level of a paramedic without paramedic education. Being taught a skill with little education to support it does not make you any less undereducated. Kind of like the navy corpsmans arguing the should be entitled to tests for RN because they did nurse like tasks.

Put on flame suit


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## EpiEMS (Jan 11, 2013)

JPINFV said:


> ...and when it comes to medicine and health care the EMT curriculum is severely lacking, therefore making EMTs lacking in education in the field they are practicing in.



We all agree on the first part -- the EMT curriculum doesn't cover enough. But this is not to say that EMTs with supplementary education are deficient. But that's not to say that EMTs who also have education in related fields are "deficient" (I don't like the pejorative word, but it's the only one I can come up with).



JPINFV said:


> I have a BS in biology, a MS in biomedical science and am halfway through my 3rd year of medical school. Would you like me to run a cardiac arrest on you or a paramedic? Who has more education? In an applied science field, you have to be able to apply the science, not just think great thoughts.



Valid point -- but couldn't it be argued that somebody with a good basic science background who is ALSO an EMT has a nice mix of both, certainly at the BLS level?




JPINFV said:


> 6 years in the Navy doing, what? A military physician and the guy who watches the front gate of the base both can have 6 years experience, but you didn't qualify the experience as anything besides a number. Furthermore, different patient populations.



Well, as a young, healthy person, I'd rather have the average military medic (an EMT-level 68W, say) take care of me if I received a serious traumatic injury than an average paramedic...But that's tangential, I suppose. The entry-level military medic is a trauma expert, no bones about it. I'm not really sure whether that necessarily means he or she is better at medical care (specifically, as in medical vs. trauma; but also in the sense of medical care as in health care).



Chase said:


> Not necessarily directed at you but it irks me when military medics argue that experience doing advanced procedures in a combat setting validates them as a superior provider and somehow entitles them in the civilian world. Just because you were shown how to perform a surigcal cric, which is a relatively simple procedure, does not mean that you should be allowed to function at the level of a paramedic without paramedic education. Being taught a skill with little education to support it does not make you any less undereducated. Kind of like the navy corpsmans arguing the should be entitled to tests for RN because they did nurse like tasks.



As a paramedic, not fresh out of the gate, sure -- but I could see a military medic to AEMT bridge being very plausible with not too much additional training (and a military medic to paramedic with roughly half a year of schooling: viz. http://www.lcc.edu/nursing/militarymedic/)


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## whitelcpl0311 (Jan 12, 2013)

I was a marine rifleman so I had a great deal of experience with Navy Corpsmen. I've seen some that are absolutely pro at dealing with trauma with a VERY limited availability of medical supplies. Of course with every profession, there are slugs that slip through the cracks. Especially in the military, where you can't get "fired" unless you reallllllllllly go out of your way. I remember one time when I thought i might have had strep throat ( couldn't speak at all, sore, high temp), I went to the battalion aid station (clinic run by corpsmen). This guy is sitting there quizzing me on my symptoms while sitting on a computer looking at Web M.D. I had no medical experience at this time but I was still like really?! I ended up going to the field for a week in early march with tonsilitis because they said I was fine to go. I was a corporal and had 16 marines that i had to get from point a to point b with absolutely no voice and a high body temperature. Of course it rained 5/7 days.

I'll add that most of my medical training in the military was taught by some meathead with a dip in his mouth, spitting into an empty monster can, swearing profusely and skipping steps. I agree with a bridge program for emtc/aemt but certainly not paramedic or RN!!


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## Shishkabob (Jan 12, 2013)

whitelcpl0311 said:


> I was a marine rifleman so I had a great deal of experience with Navy Corpsmen.



Something about this sentence does not compute...


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## EpiEMS (Jan 12, 2013)

Linuss said:


> Something about this sentence does not compute...



The Navy does provide all medical, dental, and chaplain support for the Marine Corps. USMC units have Navy corpsmen, physicians, nurses, sundry other healthcare personnel and chaplains attached.


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## whitelcpl0311 (Jan 12, 2013)

EpiEMS said:


> The Navy does provide all medical, dental, and chaplain support for the Marine Corps. USMC units have Navy corpsmen, physicians, nurses, sundry other healthcare personnel and chaplains attached.




Thank you.

Military medics are typically Non combatants.

Every Marine is a Rifleman.

The Marine Corps is a Department of the Navy.

Does that Compute?

Seriously? Like I'm some sort of invalid? 
I may not have my EMT-Basic yet, but I do have the better part of my B.S. in Biological Sciences complete.


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## whitelcpl0311 (Jan 12, 2013)

Linuss said:


> Something about this sentence does not compute...



Something about YOU to me doesn't compute. Most don't have the stones to straight up call a veteran crazy (you should probably have a very strong background before you do so). I personally don't give a damn if you're a paramedic. You can keep that career. I was posting my .02 cents. Did I deserve a passive aggressive jab? Hardly.


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## DesertMedic66 (Jan 12, 2013)

whitelcpl0311 said:


> Something about YOU to me doesn't compute. Most don't have the stones to straight up call a veteran crazy (you should probably have a very strong background before you do so). I personally don't give a damn if you're a paramedic. You can keep that career. I was posting my .02 cents. Did I deserve a passive aggressive jab? Hardly.


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## VFlutter (Jan 12, 2013)

whitelcpl0311 said:


> Something about YOU to me doesn't compute. Most don't have the stones to straight up call a veteran crazy (you should probably have a very strong background before you do so). I personally don't give a damn if you're a paramedic. You can keep that career. I was posting my .02 cents. Did I deserve a passive aggressive jab? Hardly.



Woah, easy there tiger. I can see how his post could be taken a few different ways but I do not think he is straight up calling you crazy, veteran or not. It's the interent most people are passive aggressive or rude.


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## Veneficus (Jan 12, 2013)

whitelcpl0311 said:


> I was a Marine Corps Rifleman



There is another kind?

Sorry, couldn't resist  Welcome to the site.



whitelcpl0311 said:


> I'm paying CAREFUL attention in my EMT-B class as to not get that feeling of "Oh **** i have no idea what to do" ever again.



If you never get that "Oh ****, I have no idea what to do" from EMT class, you let me know, and I will enroll in that very class next.

I give you my loyal assurance, no matter how much you learn or how long you have been at this game, there will always be days and patients that make you feel that way. 

The more you learn and know, the scarier it gets, usually because you know what the pt needs but you don't have it. You also know all the ways things could go possibly wrong.


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## NomadicMedic (Jan 12, 2013)

whitelcpl0311 said:


> Something about YOU to me doesn't compute. Most don't have the stones to straight up call a veteran crazy (you should probably have a very strong background before you do so). I personally don't give a damn if you're a paramedic. You can keep that career. I was posting my .02 cents. Did I deserve a passive aggressive jab? Hardly.



Hi all... I'm watching this thread... 

*One warning.*


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## NYMedic828 (Jan 12, 2013)

JPINFV said:


> ...and when it comes to medicine and health care the EMT curriculum is severely lacking, therefore making EMTs lacking in education in the field they are practicing in.
> 
> 
> I have a BS in biology, a MS in biomedical science and am halfway through my 3rd year of medical school. Would you like me to run a cardiac arrest on you or a paramedic? Who has more education?



Wo buddy your still just an EMT until you finish med school! :rofl:


(not serious)


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## medictinysc (Jan 12, 2013)

JPINFV said:


> ...and when it comes to medicine and health care the EMT curriculum is severely lacking, therefore making EMTs lacking in education in the field they are practicing in.
> 
> 
> I have a BS in biology, a MS in biomedical science and am halfway through my 3rd year of medical school. Would you like me to run a cardiac arrest on you or a paramedic? Who has more education? In an applied science field, you have to be able to apply the science, not just think great thoughts.
> ...



First, In all fairness I have to give you the credit that your due.  You sound like a wonderful student.  Your very eloquent in your speech and writing techniques.  Now on to the matter at hand, if I were in cardiac arrest whether it be V-FIB, pulse-less VTACH, VTACH with a pulse, or Assystole.  For someone with practical knowledge on how to perform the tasks at hand.  I don not need a doctor in my house, at my work, or in the ditch,  I need a paramedic, EMT, first responder.   Have you ever watched a doctor give orders during a cardiac arrest,  they are totally oblivious to the AHA recommendations.  They start spouting things out like "Give him an amp of dopamine"  I actually saw a nurse say what dosage would you like?  The doctor repeated "an amp".  The nurse said it's weight based,  the doctor said "Oh" I chimed up and said Dr ***** has us start out at 2 mcg/kg/min is that what you would like.... The doc looked at me and said fine.  And walked out and left it to the common uneducated workers


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## Aidey (Jan 12, 2013)

By definition vtach with a pulse is not cardiac arrest.


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## medictinysc (Jan 12, 2013)

Aidey said:


> By definition vtach with a pulse is not cardiac arrest.



Thank you I am big enough to say that I am wrong.  :wacko:  Don't know what I was thinking


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## usalsfyre (Jan 12, 2013)

medictinysc said:


> I don not need a doctor in my house, at my work, or in the ditch,  I need a paramedic, EMT, first responder.


If I'm upside down in a ditch I'd much rather have this guy coming to get me than the vast majority of paramedics....



medictinysc said:


> Have you ever watched a doctor give orders during a cardiac arrest,  they are totally oblivious to the AHA recommendations


A quick note on ACLS....the are "recommendations" that are based on standardized responses to common problems. Depending on what your knowledge of what's going on it may make sense to do something completely different. For instance the first drug I reach for in the pre-dialysis cardiac arrest is not epi, but calcium....

I also would like to know what department the aforementioned cardiac arrest happened in. I can't imagine any doc who regularly works in EM giving an order like that.


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## Veneficus (Jan 12, 2013)

medictinysc said:


> Have you ever watched a doctor give orders during a cardiac arrest,  they are totally oblivious to the AHA recommendations.  They start spouting things out like "Give him an amp of dopamine"  I actually saw a nurse say what dosage would you like?  The doctor repeated "an amp".  The nurse said it's weight based,  the doctor said "Oh" I chimed up and said Dr ***** has us start out at 2 mcg/kg/min is that what you would like.... The doc looked at me and said fine.  And walked out and left it to the common uneducated workers



I am going to have to take issue with this...

Have you ever seen me do it? I can also perform every role in a cardiac arrest as good as any nurse, tech, or medic you can summon and probably better than most.

Because I know the AHA recommendations inside and out, not only do I teach them, I am the guy the teachers call to answer the questions they cannot. 

When it is in my power, I do not use the AHA recommendations. I promise you nobody is getting epi unless they have a specific pathology I can identify that requires it.

Second of all, you cannot compare military docs to civilian docs. They are in all respects 2 seperate worlds with 2 different measures of success. 

Third, while the dopamine thing is disconcerting, maybe that doc works in an environment where he doesn't usually treat cardiac arrest because it is futile?

I can tell you if somebody codes in Afghanistan, from something other than penetrating trauma or a handful of immediate complications from treating it, they are 99.9% likely going to die.  

Fouth, the AHA guidlines are designed for sudden cardiac arrest from the most common cause in the civilian world, which is an MI. They are not designed to work in any other etiology.

finally, a doctor at any civilian institution anywhere in the world I have been that walks out on an active cardiac arrest and doesn't leave the patient in the care of another doctor is probably looking at his last day at that facility, and will probably be answering to a legal or professional authority for such conduct.


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## JPINFV (Jan 12, 2013)

medictinysc said:


> First, In all fairness I have to give you the credit that your due.  You sound like a wonderful student.  Your very eloquent in your speech and writing techniques.  Now on to the matter at hand, if I were in cardiac arrest whether it be V-FIB, pulse-less VTACH, VTACH with a pulse, or Assystole.  For someone with practical knowledge on how to perform the tasks at hand.  I don not need a doctor in my house, at my work, or in the ditch,  I need a paramedic, EMT, first responder.   Have you ever watched a doctor give orders during a cardiac arrest,  they are totally oblivious to the AHA recommendations.  They start spouting things out like "Give him an amp of dopamine"  I actually saw a nurse say what dosage would you like?  The doctor repeated "an amp".  The nurse said it's weight based,  the doctor said "Oh" I chimed up and said Dr ***** has us start out at 2 mcg/kg/min is that what you would like.... The doc looked at me and said fine.  And walked out and left it to the common uneducated workers




Can't say I've seen that... and every resuscitation I've seen in the ED tends to flow very smoothly. 

Plural of anecdote is not data. Of course I'd also expand the qualification of educated vs not educated to physicians in regards to emergency care too. There's a difference between describing, say, a dermatologist in an emergency situation and an emergency physician... unless it was an emergency dermatology patient.


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## Veneficus (Jan 12, 2013)

JPINFV said:


> There's a difference between describing, say, a dermatologist in an emergency situation and an emergency physician... unless it was an emergency dermatology patient.



There are emergent dermatological pathologies?

I had no idea...

I thought all of those were punted to Rheumo or Onco.


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## JPINFV (Jan 12, 2013)

Veneficus said:


> There are emergent dermatological pathologies?
> 
> I had no idea...
> 
> I thought all of those were punted to Rheumo or Onco.




SJS/TEN spectrum is one. I also tend to hedge my bets when ever I can.


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## NomadicMedic (Jan 12, 2013)

*Back on topic please. *


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## Shishkabob (Jan 12, 2013)

whitelcpl0311 said:


> (you should probably have a very strong background before you do so).



You mean BESIDES MCRD San Diego that I have?




EpiEMS said:


> The Navy does provide all medical, dental, and chaplain support for the Marine Corps. USMC units have Navy corpsmen, physicians, nurses, sundry other healthcare personnel and chaplains attached.



No, see, I know that better than most considering my background.


What didn't compute was a Marine not capitalizing "Marine", but capitalizing "Navy" and "Corpsman".  Hence, does not compute.  Every Marine I know would jump on that miss-classification pretty darn fast.


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