# EMT-Basic: Is 120 hours enough?



## JPINFV (Feb 6, 2008)

People have been complaining that I'm too harsh with my criticisms of EMT-B training and education. As a preface, let me say that critiquing a level is different than critiquing a person. Saying that x level is undereducated for what they do is criticism of the system, not any one person. If you feel personally injured because you're a basic and disagree with me, then let me apologize in advance, it's not personal. Furthermore, let me put out that policies, rules, procedures, and protocols *must* target the lowest common denominator, not the best and brightest. There can not be one treatment standard for EMT-Bs from one course and a completely different standard for EMT-Bs from a different course. 

Is 120 hours enough? I say no. EMS personal work in an acute system away from many of the safeguards that are found in the hospital. Many times, there are no extra providers on scene [versus, say, a hospital. There isn't a pharmacy to discuss medications with, there isn't an RT to assist managing respiratory problems, there are no physicians on scene] as there is in a hospital. Yes, we do have "protocols" [which, in a representative number of systems, are guidelines and suggestions, not cookbook treatment plans] and online medical control [mostly, though there are exceptions though]. Even with online medical control, a provider has to have the education and training to understand what needs to be communicated to the base hospital. The provider must be able to operate, at the very least, as an interface between the physician and the patient, the proverbial hands and eyes.

So, I ask again, in a system like this, is 110 hours, give or take, enough? When 99% of medical scenarios in a given training class can be answered, regardless of the complaint, with a stock reply of "high flow O2 [15 LPM, of course, because the National Registry, whose tests are based off of the DOT standards, thinks that 120 hours isn't enough to decide between high and low flow, or even 10 LPM and 15], call someone else [paramedic intercept], position of comfort, and transport immediately" are we, as providers, really helping patients? Now it should be noted that treatment 'stops' not because there's nothing else the patient might need, but simply because the provider is out of options. 

Let's look at the drugs that EMT-Bs can administer based on their assessment under DOT training standards [so no pre-prescribed "patient assist" drugs]. The drugs are simply oxygen, activated charcoal, and oral glucose. Some systems have expanded their scope of practice and protocols for EMT-Basics to include narcan, nitro, albuterol, and/or epinephrine for anaphylaxis shock (based on the EMT-B's assessment and judgement, not based on a patient's prior prescription for the medication), but these systems are hardly representative of EMS as a whole. The entire required pharmacology education and training for EMT-Bs [note: This *includes* patient assist medications] is one hour long. Is 1 hour honestly long enough to understand the what, why, and how of how oxygen is used by the body? The answer is no.

"Surely," you ask [and don't call me Shirley], "normal body functions is covered in depth during the A/P portion of the course?" Well, let's look at that, in terms of hours. The "Human Body" section required by US DOT is a only 2.5 hours long. Again, this is for all of the physiology and anatomy for the entire course. Therefore I put forth that the knowledge base required for EMT-Bs, especially since most courses don't require prerequisites such as anatomy and physiology, that the rest of the training is built around is woefully weak.


Now let's look at what EMT-Bs can do again for medical patients before they start circling the drain. We can use oxygen, glucose, and activated charcoal. Glucose can't be used in patients who are unable to maintain their own airways and activated charcoal is only useful in patients who ingested poison. Therefore, the only useful medication in the majority of medical patients that EMT-Bs can administer is oxygen. Even then, EMT-B education as it currently stands is woefully inadequate in even educating providers on how that drug is used by the body. If I, or a loved one, ever need emergency, I'd hope that the provider would be able to do something to reverse the cause of the emergency then engage in a mere stop-gap procedure. 

Therefore, I propose that the 110 hours required by the DOT for EMT-Basics should be increased substantially. 2 hours of anatomy and physiology and another hour of pharmacology is not sufficient to warrant increasing our scope of practice drastically, considering that the current education is not sufficient for understanding what our current procedures and assessments are telling us. 

Comments? Does anyone think that the current amount of education required of EMT-Bs is sufficient for practice in an uncontrolled environment? Furthermore, how do you reconcile the fact that parts of Canadia require their entry level worker to have a 2 year degree instead of 110 hours?


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## firecoins (Feb 6, 2008)

The need for vollie systems requires volunteers.  So the course has been somewhat washed down.  

A&P is not really covered in EMT class. At least not sufficently. As a medic we take A&P I and II, 2 semesters outside of medic class.  EMTs really should do the same.


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## Ridryder911 (Feb 6, 2008)

Well let's put in perspective. The EMT anatomy is the same length of 2 and a half American Idol shows, and the EMT Course is basically one season of Gilligan's Island. 

Yes the course is long enough for what it is should be. First responder/first-aid course. Is it long enough for delivery of emergency care ? NO. It is Not even long enough to begin with. 

I will challenge anyone to prove differently. Now with that perceptive, why is it so many volunteer organizations protest increasing length of courses and increasing training? If we all agree it is sub-par? Again, most of it is back to ego's and tradition not for the benefit of the patient. 

What would we say if Police, Fire or even some form medical licensed professionals refused to increase their knowledge and provide better services?  Truthfully it is shameful and embarrassing that we do not have more an outcry. Yet, look around on how many EMS personnel would actually want to increase the requirements. Just read on how boisterious the comments are that they attended a nighttime 150 hour course. Heck, my class on patient's spiritual needs was longer than that. 

So one should understand why peers of those in EMS (nurses, respiratory therapist, even ultra sound tech.'s) do not glamorize the length of an EMT course. If one examines the core curriculum and even the skills taught, it still is still rated a nominal and a beginner course. Again the reason the wording Basic is emphasized. It is not degrading, just it is what it is.

So many describe the EMT course as difficult and this is usually because it is one's first exposure to any medical training at all. If one evaluates the over all pass rate of EMT programs and tests, one can see that it has a large drop out rate and low fail rate from those that do graduate and take the certification test. Again, this is in comparison to other medical board test.

The Basic definitely has a role. It is that role that has to be redefined. 

R/r 911


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## LucidResq (Feb 6, 2008)

My EMT course is 238 hours. I agree with you, 120 hours is not enough. However, I think many of the skills that should be learned for someone to become an excellent care provider can only be learned while actually providing care, so although I think 120 hours is a little short, I don't think more classroom time is necessarily the answer. 

I think there has to be intrinsic motivation for someone to want to make that extra effort to become excellent also. With many people you could spend a year teaching them a&p, test them on it 5 times, and once they know they won't be tested on it again they'll forget every freakin' thing they "learned". 

Someone has to be motivated from within to go above and beyond. I wouldn't feel comfortable treating people if I didn't know anything about the body or if I didn't know what all those big words meant, so I took anatomy and phys and medical terminology before I took my EMT class. 

Basically, some people will know that they need to give someone oxygen because that's what the textbook said and that's what they were tested on. Others will give someone oxygen because they understand the physiological process of their acute disease and know how it can be treated.


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## Kazz (Feb 6, 2008)

I beleive the one im taking (NYS) is 180-200 somthing hours long?  I know for a fact were spending 6 hours on pediatrics and 6 on drugs.


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## Outbac1 (Feb 6, 2008)

WOW, 110 hours, thats all?? I knew an US EMT-B course had less time than a Canadian Primary Care Paramedic course. But didn't realize it was so little. That explains a lot of the EMT-B questions here. The background training just isn't there. 
 I took my PCP in 2001 when our new National Occupational Competency Profile (NOCP) was brand new. (For more info on the NOCP see the Paramedic Association of Canada website www.paramedic.ca) The total course was 10 months. Included was 60 hours of A&P, and 90 hours of pathophysiology. This time did not include one minute of hands on skill. There were of course numerous other subjects and lab,(hands on ) time. Then about 100 hours of hospitial clinical and 264 hours of preceptored ride time in an ambulance. Ride time has since gone up to 504 hours. I think my total course was 1200 hours and cost with tuition, books and uniforms about $12,000.00.
 For the most part in Canada we don't have private health care. It is all government run and tax dollar paid for. That doesn't mean everything is free or we have a perfect system because we don't. We have our share of problems. 
 Each province operates its health care differently. Here in Nova Scotia  we now have one provider of ground and air ambulance service. All trucks are equipped the same and we have standard protocols province wide. I invite you to look at our provincial web site for more info. www.gov.ns.ca/ehs/
 Nova Scotia is almost as big as West Virgina and about half its population. We are about 21,000 sq miles and 950,000 people.
 Its been a long time coming because about 14 years ago all you needed here was a two week Emergency Medical Assistant course and you were good to go. There were about 50 private operators then, all of whom were bought up by the government and a single private operator hired to run the ambulance service. The public is much better served now.
 Our neighbouring province New Brunswick is just now starting to emulate us. The private operators are now gone and a single operator is running the province since Dec/07.  What a co-incidence it is another company owned by the company that operates Nova Scotia. Hopefully they can be brought up to speed quicker. It just costs money.
 Everyone who works in N.B. who is not up to PCP standard must get educated to PCP within three years or they are out of a job. 
  Just some comments on what is going on north of the border.


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## TKO (Feb 6, 2008)

Do you still have EMRs in NS?  We have EMRs working in BC, some remote stations are still entirely EMR operated (relying on local clinics).  Not much for ACPs in most parts, so PCPs have a lot more drugs and protocols than other provinces....we're getting Morphine and ETT soon too, and advanced cardiac is being reviewed.

EMRs here are educated in 12 days x 8 hrs = 96 hrs.  They are basically the equivalent of an EMT-B, they need their first aid and CPR before they can start their EMR course.  I think the EMR course needs more time behind it too, but everyone has to do a six month probation of riding 3rd (well, PCPs generally get through that much quicker).


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## lcbjr3000 (Feb 6, 2008)

Ive been working as an Emt-b for one year. I feel that after the course  I was not well enough prepared for work as an emt. I was hired before i started the classes and was told that afterwords there would be a month of OJT. I worked as a third member of the crew and watched and learned how the classroom translated into the real world. You can only run so many scenarios but until you actually see it, it doesnt seem to sink in. I slowly began to do assesments and other skills required of the emt-b and then before i knew it I was working as a crew memeber. Personally I feel I learned more with OJT however if not for the foundation that was provided in the classroom i would have been lost. If there were a way to keep the classroom time the same, but add clinicals and internships like the paramedic program im in does then I think we will begin to produce emt-b that are more prepared to step into their role and be excellent healt care providers.


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## Ridryder911 (Feb 6, 2008)

Unfortunately U.S. has dropped the ball. We might have started the game but realistically nothing has changed much in the past 30 years. Sure, we have some new toys and treatment modalities that might have changed somewhat but as a systems it has became stagnant. 

In comparison of those from the North Border and those from below in Australia and parts of Africa we are negligent in upgrading our system. Sure we are more advanced than some third countries, we can develop a wireless tracking system for our pizza yet not all communities have 911. Physicians can review ultrasound from a flying helicopter to triage to go to surgery, yet 20 miles away a patient awaits for a volunteer first aid squad to gather and then go to their house with the best treatment available is an aspirin and oxygen. Anyone else see a problem here? 

Unfortunately EMT's are not educated about the system they work in. So many assume EMS is just about ambulances and fail to recognize prehospital care is just one small part of the system. EMT's usually do not care about professional development, system analysis, research and development. Rather they are concerned about how many lights and scanners can one plug into the auto without blowing a fuse. Don't believe me, read the posts. 

We wonder why we are treated the way we are?  In the words of  Dr Phil.."_people treat you they way you expect them too"_.. so what do we expect? The manicurist attends a longer course to cut your toenails than an EMT attends their course... and we expect what? 

R/r 911


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## VentMedic (Feb 6, 2008)

I find it very difficult to teach an EMT-B class or even the refresher.  There is so much more I want to explain, demonstrate or have the students see for their clinicals, yet there is not enough time.  The other factor is the way the time allowed is structured.  Yes, ride time is important but so is patient contact.  I would like to see more assessment skills perfected on actual patients in a controlled environment.  I would like students to be proficient at the skills they do learn like BPs, breath sounds and respiratory patterns so they can be applied under more environmentally unfriendly situations like the back of a truck with sirens blasting or in a house with 10 family members yelling at you. 

I would also like to see more infection control, bloodborne pathogens, legislative, ethics and HIPAA updates added to the refreshers.  I don't believe time should be spent for a State Refresher reviewing basic A&P or skills that should be already be monitored as competencies by the training officers of the companies.


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## LucidResq (Feb 7, 2008)

I definitely agree with you VentMedic. The EMT course is so focused on assess, load and go, people don't realize how many other factors are at play. I had a basic background on infection control, BSI, HIPAA, medical terminology, anatomy and phys, and communications before I started my EMT class and it makes me  worried that we went over it all so briefly that we only needed 3 class periods to cover all of that. 

I'm really glad that one of my clinicals is spending an 8-hour shift doing nothing by vitals with the triage nurse and a level 1. I look forward to it, because I know that right now I would hate to imagine a patient truly relying on my ability to take an accurate blood pressure or find a pedal pulse. It's a skill that needs to be practiced often and on a wide range of people in a wide range of situations.


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## TheAfterAffect (Feb 7, 2008)

All im going to say on this is that 120 might not be enough, but I know at my Squad your a Probie for about a year so thats kinda more hands on training time towards you.


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## Outbac1 (Feb 7, 2008)

To answer TKO. Yes we have EMR's. But they are called MFR's ( medical first responder not emergency medical responder). Is there another way we can mix up the alphabet to say the same thing so we can become more confused? Our MFR's are volunteer, mostly with fire depts. and may be first on scene to provide initial care.  Some depts. operate that they go to all code 1 medical calls and others at paramedics request. For us we only have two codes. Code 1 is with lights and siren and code 2 without. They have about two weeks of training, can start an assessment, give O2, take a bgl and give oral glucose. I'll have to check to see if they can give ASA and nitro. They also extracate backboard and collar. They do NOT transport.
 We are getting more ACP's as more medics upgrade but they are still scarce in the rural areas. At our base we have 26 medics. 10 ACP, 9 PCP, 7 ICP. The ICP was a stopgap measure from about 10 years ago to get als when there were few ACP's.  They can do IV's, intubate dead people, give morpine and valium, and in an arrest give epi, atropine, and lidocaine.That's about it. The province stopped registering ICP's about 6 years ago.  So there are no new ones. The only exception is if an American EMT-P wants to get registered here they will temporally register them as an ICP. They then have one year to write the provincial exam. If they pass, (and they do), they get registered as an ACP.
 Now out of curiosity what do various people get paid for their registration level? How many hours in your avg work week? 
Here a new PCP gets $17.50 hr, with 5 years exp. $19.90. An ACP starts at $21.50 and with 5 years exp. $24.50. I might be out a few cents as I haven't got my book handy. We work an avg. 42 hour week plus overtime if you want and there is always lots. We do mostly 12 hour shifts in a two day two night four days off rotation. Some of the quieter rural bases work 24 on 72 off. Our contract is up soon and its nice to know whats around.
 Nova Scotia will not consider registering EMT-B's. 
 I believe Rid is right. You started the ball rolling but have let it pass you by. If you want to move ahead you must push for change from within.  Look at our and other countries sucesses and our mistakes. Learn from them and make a better system. It won't be easy and it will cost a lot. But it is doable.


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## BossyCow (Feb 7, 2008)

firecoins said:


> The need for vollie systems requires volunteers.  So the course has been somewhat washed down.
> 
> A&P is not really covered in EMT class. At least not sufficently. As a medic we take A&P I and II, 2 semesters outside of medic class.  EMTs really should do the same.



I agree that the standard is too low. We should all have basic A&P and also Medical Terminology and some Pharmacology. 

I disagree that its the volly system that brings the standard down though. For a transport agency that will replace an EMT every 2 - 3 years, whose rig is never more than 10 minutes from a hospital with ALS available on all calls, there is no need for a higher standard. They can (and some say do) train monkeys to be EMT's in those systems. 

Currently those who take their responsibilities seriously, will take their education seriously and will be learning througout their careers, regardless of cert level. Currently, from a business standpoint, the current standard meets the needs of the agencies hiring EMTs so there is no impetus to change. If they want higher skills, they hire a medic. If they have a priority on staffing with high quality, well trained, experienced EMT-Bs, there there enough of them around to fill that need. 

Nobody's going to fix what ain't broke, and though we wish it could be better, there will have to be a few more lawsuits and the insurance agencies will have to dictate a higher standard before anything changes.


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## EMT19053 (Feb 7, 2008)

I agree that the Basic class is probably to short, however, where I am from all of the EMT's are vollie with full time jobs. It is somewhat difficult to juggle work, class and family at the same time. It is already difficult to recruit EMT's out here let alone making the class longer. The closest ALS for our service is 180 miles away and the hospital is what some people call a bandaid station. I think that the EMT-B's in areas like mine are more interested in learning and becoming better providers unlike the trained monkeys that Bossy refers to because to them its a job and out here we do it to help people. It is tough when you don't use the skills and knowledge every day like some but we do the best we can and learn something new on every run.


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## Meursault (Feb 7, 2008)

I'll let someone else *coughRidcough* explain how the last post proves their point to a T.

I'm not sure urban/suburban BLS is quite as horrible as Bossy portrays it. Yes, between high turnover and multiple competing agencies, there's not much incentive to train EMTs to a high standard. On the other hand, in my area, nearly all EMTs with private companies spend their days doing noncritical interfacility transfers. It's a job that could be done by a trained monkey, and so the EMTs are treated and trained as such. 

In the examples frequently brought up by critics of all-volunteer BLS, EMTs are the sole 911 providers for miles. They might be better trained and motivated than your average private IFT employee, but the deficiencies in their training as compared to medics become much more significant in emergencies. 

As other posters have pointed out, criticism of those systems is not criticism of the individual. Similarly, I'm quite sure that some posters here feel that their colleagues are better trained/more competent/too busy to go to medic school.  It might even be true. Regardless, if your system or any other cannot deliver quality care, something needs to change.


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## TKO (Feb 7, 2008)

Outbac1 said:


> Now out of curiosity what do various people get paid for their registration level? How many hours in your avg work week?
> Here a new PCP gets $17.50 hr, with 5 years exp. $19.90. An ACP starts at $21.50 and with 5 years exp. $24.50. I might be out a few cents as I haven't got my book handy. We work an avg. 42 hour week plus overtime if you want and there is always lots. We do mostly 12 hour shifts in a two day two night four days off rotation. Some of the quieter rural bases work 24 on 72 off. Our contract is up soon and its nice to know whats around.



Wow!!  BC is looking damn good!  Even SK (where I came from) pays better than that.  I make $20.17/hr and ACPs make $30/hr to start.  We receive an increase of $5/hr after 5 years.  And we are currently VERY upset with the employer because they made a deal with our membership to provide us with a raise this month (we haven't had one for 5 years) and they didn't even show up with a proprosal.  We're headed towards a "strike" next year.

There are some serious down-sides that we are fighting against too.  I work 250+ hrs/month (when I give 100% availability) and I only get paid $10/hr between call outs.  I receive 3 hours pay on any call out, but if 2 calls are together within that 3 hours, I only get the 3 hours.  If those 2 calls last 4 hours together, I get paid for 4 hours.  I've had days where I put in a call and 2 minutes before I clear I have gotten another call and it just extends the original call.  This is called a Foxtrot shift.  We are fighting to get rid of it because it is a full-time station and we deserve full-time pay.  

There's also Kilo shifts where they don't have to be at the station and some people work other jobs at the same time and just wear a pager.  They get paid $2/hour because they seldom get a call but receive 4 hours for every callout regardless of whether they run together or not.  The quality of service in those stations isn't excellent because of the response times and often EMR-only trained rescuerers.  This sounds almost acceptable for the money, but a lot of PCPs have to start in kilo stations and go further into debt.  Someone trying to make a career out of EMS will get royally screwed for their first 6 months if they have to start in a kilo station.

We don't have ICPs here, but did in SK.  PCP and ICP is almost the same level tho between the two provinces.  Here, we have about a dozen meds to give, IV therapies, etc.  We're getting Morphine (don't really want it) and ETTs and some advanced cardiac drugs and protocols.  BC doesn't train as indepth on ECGs as SK did because they don't have monitors on BLS cars, but as a depaired ALS PCP, you will get that access.

Not much for ACPs around BC, so we are ALS out here.  Really, I am highest level so it never occurs to me that there are situations that I would radio for ALS anymore.  There are definitely times that ALS would be required, but when you don't have it you adapt.


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## Topher38 (Feb 7, 2008)

I think the clinical time should be longer as well. I learned alot in the classroom but when i did my ride time with paid EMS i learned ALOT just by watching and helping with vitals. Clinical req. is only 10 hours i think. Which is enough for what 4-5 calls on a regular day. But yea 120 hours isnt enought. Fo show.


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## skyemt (Feb 7, 2008)

Here is one of the great ironies of this forum...

when the question of inadequate education comes up, everyone, including the paramedics chime in with criticisms of the basic education, and rightly so...

BUT... often when basics ask questions, be them scenario based, or questions based on info higher than a basic cert, very few paramedics join in with educational "teaching".. sure, a few most always do, and they know who they are... but MANY on this forum do not.

so, if a great many paramedics on this very site will not step up in the education of basics on this site, why the heck would anyone think it would happen on a much larger scale.

if you want the education to be better, the more educated on this site have an opportunity to start here. 

where are the threads where paramedics want to teach basics? not too many, actually.  is it your responsibility to do this? no. but if you choose not to, which is fine, don't come back and complain that the educational standards are too low.  it's all about continual education, and there's no better place to start than here. it's one of the reasons i continually visit this site. to learn. not to read a thousand threads about what we already know, that the educational standards of basics are too low.

so, those with higher education, how about passing along some of that knowledge, and make us all think and get better educated!


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## indygirl14 (Feb 7, 2008)

I'm gonna chime in on this one....although maybe I shouldn't...

I'm currently a month into my EMT-B classes, and I already see that I wish we had more time.  We spent eight hours on A&P, which it sounds like is more than what most get, however, it could have been much much more.  This is really one of the reasons that I'm seriously thinking about Paramedic Training...I just want more of this...I want more time to get confident in what we are learning.  I want more clinical time (we are required to do 24 hours on the ambulance and 24 in the trauma center).  I want more A&P (did I really just say that ).  I want more airway.  I just want more of it.  I want to know that I am providing the absolute best care that I can, no matter what level I'm at.

I understand that there needs to be a difference between EMT-B and EMT-P...but at least DOUBLE the requirements for EMT-B.  I mean...twice the time that we have to do this stuff, would be so nice. 

But, since for now, it is what it is...I'll absorb as much as I can and spend as much time on the ambulance and ER as I can...and then move into Paramedic school


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## VickiEMTfire (Feb 7, 2008)

I feel although 120 hours does not seem like near enough time to learn all you need to know to do patient care in the field it is like anything else you take on. The more you put into it, both in class and outside of class, the more you will get out of it. I suggest if you want to have the best advantage to go out and be able to perform the skills you learn in class you need to take it upon yourself to attend other outside classes usually offered by local fire departments or hospitals. I definitely suggest you attend an ALS assist class! There are also many books out there that can help such as an A&P book.The more you take upon yourself to learn, the more prepared you will be.
   You also need to remember you are never prepared for some things you will see and do until you are in the situation.Just take a deep breath and do what needs done.You will be fine.
   I am currently about half way through my paramedic course and believe me I feel totally lost and unprepared right now.I know that it will all come together and make sense and when I am in the field for the first time as a medic I will be nervous but I will take that breath and do what needs done.There is always later, sitting in the station, to panic or cry.
   Good luck to all newcomers,you will make a difference in someone's life!


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## TKO (Feb 7, 2008)

I feel that the less education you have, the less the employer will have to pay you.  And I believe that's a big reason for the low standards of EMS.  
"If you don't go to college and have certification and a restricted medical license, why should they pay you more than a few bucks over minimum wage?" appears most often to be the motive of the system.  I really believe that the allmighty dollar is behind the majority of our professions short-comings.

There is no justifiable reason that any person in the industry should have to work extra hard to make themselves a better rescuer and more knowledgable at their own expense.  Especially for the sole benefit of their pt's care, it should be already be available.

It is time that the public learned the truth of the system and this stopped.  EMTs deserve a better education and consequently better pay, and the public deserves a better emergency care system.


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## BossyCow (Feb 9, 2008)

MrConspiracy said:


> I'm not sure urban/suburban BLS is quite as horrible as Bossy portrays it.




Hey, only some of them, by no means did I intend to imply that all are that way. But there are those systems out there, we've all seen them and worked with them.


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## MSDeltaFlt (Feb 9, 2008)

My thoughts on the course is this:

I believe the didactic portion might be long enough.  HOWEVER, I believe that the clinical portion should be seriously increased.  EMS should be an apprenticeship; on ALL levels.  the book can never teach you everything you need to know.  You can't teach experience.  You must experience it.  You must be an apprentice.

My honest, yet humble, opinion.


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## JPINFV (Feb 10, 2008)

I do find it interesting, though, that after suffering ad hominem attacks over the issue in a different thread [since cleaned by admins], no one seems to fully disagree that EMT-B is not long enough. 


I do agree that EMT-B should be extended both in the diadatic part and the clinical part. Even if you don't remember every single minute detail from an anatomy and physiology courses, students should still leave the courses with an understanding and respect of the major themes. You can't consider different differential diagnosises [yes, we don't "diagnose," but we come as damn close to that line as possible, even as an EMT-B] if you don't know that they can even exist. Similarly, you can't really consider assessment tools if you don't understand what they're really measuring [this goes back to the mantra "treat the patient, not the monitor"]. It is this problem [lack of diadatic education] that will prevent our scope, and therefore our ability to provide care, from being increased. 


Another reason is that, as long as the entry requirements are so low, anyone with two brain cells can pass. Sure, the providers that value their medical care will continue their education, be it in theory [A/P, pharm, etc. I'm talking about formal education] or practical [focused Con-Ed, higher cert level (moving from basic to paramedic)], but think about it for a minute. The person requesting a call for service doesn't get to pick and choose who their responder is going to be? Do you really want to roll the dice that the provider answering your 911 call is going to be someone who wants to learn?

Similarly, if you're 2 hours away from advanced life support and an hour away from the hospital, shouldn't that mean that you [generic "you", not directed at anyone] should be more educated since you don't have a paramedic safety net to fall back on?


The clinical part of the education should be increased as well. It's all fine and dandy to talk and teach about how to deal with the ideal situations, but as the cliché goes, patients don't read the manual/protocols. The clinical part is where the theory gets integrated into the practice of medicine. This is especially true since regional variances [my favorite example is DNR procedures] will always trump what the text book and teachers tell their students. My EMT-B course required 8 hours of ambulance ride alongs. That was a total of 2 calls [I even pulled a second ride along, at a different station and only got 2 calls on the second 8 hours as well. This was in the middle of Orange County, CA, not exactly your backwoods, low call volume area]. 

Finally, there is the issue of pay. This is, in the end, a chicken and the egg situation. Reimbursements won't go up as long as every 2 weeks to 3 months another batch of wide eyed providers graduate. First, as long as the procedures that can be done  are low, the amount that can be requested and lobbied for reimbursement [BLS vs ALS 1 vs ALS 2, Medicare payments, for example], the pay will remain low. Second, as long as there are vastly more EMT-B providers then there are jobs, then pay will remain low. there's a reason that a certain 911 provider in my old area payed $3 less per hour than the local IFT companies [$2/hr less than one of the local waterparks]. The answer is simple supply and demand. This is the same reason that the mean hourly wage for garbage men is about 50 cents higher than EMTs [B, P, or otherwise] [http://www.bls.gov/oes/current/oes_nat.htm#b00-0000 Emergency Medical Technicians and Paramedics vs Refuse and Recyclable Material Collectors]. Simply put, even though there is vastly less at risk with your garbage man, less people want to do it, so the wage is higher. 

On the other hand, providers will complain about the pay vs education problem until a higher wage is offered for more education [example: paramedic students deciding against an associate degree, or even a BS [not wanting to go into education or management at that time] because everyone, in the end, will be payed the same in a lot of systems]. The problem is that it is easier to raise education standards and THEN request a higher wage, then ask for a higher wage to get a higher education.

Therefore, before anything changes at the BLS level, and by connection, the rest of the profession, education must first be increased. Most, if not all, of the problems facing EMS would be solved by requiring more education.


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## Topher38 (Feb 10, 2008)

I have to agree with JPINFV, I enjoyed the clinical time ALOT! I learned alot during the clinical time because I actually saw how it was done and how it is diffrent in the field. 

I think it would improve the EMT student much much more if the clinical time was atleast double it is now. 10 hours is not much, 1 shift maybe 2 depending where you go. And alot of people do clinical time at thier own VFDs.


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## BossyCow (Feb 10, 2008)

I think a lot of systems figure that your first 90 days of probation on the job are your real clinicals. Most systems pair you with an overseer/babysitter until they are sure you aren't a bone head. 

I've heard over and over that the 'real' education comes in the field. The problem with that type of thinking is the supposition that your precepter in the field is going to be worth a crap or even want to be holding your hand or powdering your behind.  

I would love to see more background in A&P/Medical Terminology and call me a heretic, how about some basic communications skills, like report writing, spelling and grammar. Being able to communicate what we saw in the field to those of higher education than us, is important. Lets not make it tougher on them by having to play a guessing game with our reports. 

But I'm not going to hold my breath. I'm seeing less rather than more when it comes to education in this field. The prevalence of on-line CME and the reduction of an instructor's role in the actual education of the student has me very, very afraid. There's the attitude that after a while in the field, everyone already knows everything and CME just needs to be a tacit nod in the direction of risk management record keeping. 

_(BossyCow steps off her soapbox and awaits the :censored:storm to follow)_


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## Ridryder911 (Feb 10, 2008)

My state requires 48 hours clinical time for basic level, even then that is so little and ridiculous. Majority Basic Level clinicals are observation only. Truthfully, what are they going to do?  Vital signs, assessment (non in-depth) application of splints and oxygen. Discussion of physiological responses, pathological etiologies has to be kept a minimum. Treatment modalities has to be kept simplistic. 

Scrap the Basic level altogether. Require an associate level for entry point as Paramedic with at least 1000 hours clinical time within in the program . Then require one year residency (licensed as probation/intern) time for the first year. Continuous review at intervals for evaluation. After successful completion, then one can acclaim Paramedic level and full license and then be able to work in the field as an individual. 

Basic level should be considered as a first responder level for agencies such as fire, police and volunteer responders. Those that responsibility is to stabilize until relieved by another EMS responder. Initial care to maintain life, until ALS can arrive. 

R/r 911


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## emtwacker710 (Feb 15, 2008)

I believe that the 120 hours is enough for the Basic EMT, If you are a member of a squad or FD, then they usually have drill nights or have some sort of training program where you keep refreshed and also learn some new stuff, like I know our local hospital has lectures at least once a week if not twice on wide variaties of medical and trauma emergencies, I believe the most recent one we had was syncope and the one before that was hypothermia...so no matter how much you learn in class, you still continue to learn more once your out.


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## Arkymedic (Feb 15, 2008)

emtwacker710 said:


> I believe that the 120 hours is enough for the Basic EMT, If you are a member of a squad or FD, then they usually have drill nights or have some sort of training program where you keep refreshed and also learn some new stuff, like I know our local hospital has lectures at least once a week if not twice on wide variaties of medical and trauma emergencies, I believe the most recent one we had was syncope and the one before that was hypothermia...so no matter how much you learn in class, you still continue to learn more once your out.


 
This is an exception and is most definately not the rule.


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## skyemt (Feb 15, 2008)

emtwacker710 said:


> I believe that the 120 hours is enough for the Basic EMT, If you are a member of a squad or FD, then they usually have drill nights or have some sort of training program where you keep refreshed and also learn some new stuff, like I know our local hospital has lectures at least once a week if not twice on wide variaties of medical and trauma emergencies, I believe the most recent one we had was syncope and the one before that was hypothermia...so no matter how much you learn in class, you still continue to learn more once your out.



That is called CME, and is how most emt's recertify these days, at least in our area...

has absolutely nothing to do with the fact that 120 hours is not nearly enough.

you are combining two separate issues... initial education, and continuing education.


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## VentMedic (Feb 15, 2008)

skyemt said:


> That is called CME, and is how most emt's recertify these days, at least in our area...
> 
> has absolutely nothing to do with the fact that 120 hours is not nearly enough.
> 
> you are combining two separate issues... initial education, and continuing education.




As I mentioned in an earlier post, in some states the recertification requirement is a "refresher" or a review of what you should know and utilize on the job.  Rarely do they present anything that is a _continuation_ of what you have learned.  It is essentially like taking a mini EMT-B class again.  

I find it fascinating that many volunteer squads do take their skills maintenance and continuing education seriously.  It is difficult to get paid people to attend any class that is not mandatory.  For the recert class, they prefer to do it in a weekend or two.  Some may even have their trainers who work for their company sign them off without taking the class so they can stay on the job at the benefit of the company for a warm body on the truck and not an educational opportunity for the employee. 

Hospitals and community colleges usually have great CME or CEU classes that are relatively inexpensive.  Many educators from the hospitals and these colleges are usually willing to offer onsite classes also.  However, there is rarely a good turnout even if the classes are free for the EMTs or Paramedics.  They also may not want to take classes from anyone but another EMT or Paramedic.  Thus, they may get a limited amount of classes and a limited view of the world of medicine.


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## Megz7464 (Feb 15, 2008)

yea the emt-basic course im taking right now is 131 hours....but i see it as that if you can pass your modules and your test, you have learned and know what your suppose to be doing....what else do you think they need to factor into that would require it to be longer?:mellow:


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## JPINFV (Feb 15, 2008)

Megz7464 said:


> what else do you think they need to factor into that would require it to be longer?:mellow:



Enough anatomy and physiology so that you [generic "you", not directed at the poster] know what you're doing. Did the course cover Sterling's Effect? Hopefully they did if they're still teaching Trendelenburg position. 

How about oxygen dissociation curve? 

Glycolysis-Krebs-Electron Transport Chain [at least talked about it, not neccessarily step by step]? This integrates the importance of both glucose AND oxygen pretty nicely.

How the body maintains blood pressure, and by connection, the importance of the patient's mean arterial pressure?


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## Rob123 (Feb 15, 2008)

*Not long enough*

Hello,
I've been a long time lurker but this thread finally motivated me to make my first post.

I am almost complete with my EMT-B course in NYS.  I honestly don't think that the limited class time is enough. I am pulling tours as a dispatcher with my vollie and taking the course at night since I go to work during the day. Even with my hectic schedule, I would appreciate if we can go more indepth on many of the topics.

The sad part is, I have often joked that I learned most of class topics during Boy Scouts first-aid training... except perhaps emergency childbirth and WMD.  I'll have to add the "nail technician training hours" to my comedic repertoire.

All jokes aside, I would really consider that EMT-B course should really be more of a first responder (CFR) course.  However, as devil's advocate I would say that since there is a receiving hospital within 10 minutes of any location within City limits, "load and go" would probably still provide adequate care in many cases.

Robert
(Still in training and quite naive)


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## JPINFV (Feb 15, 2008)

Rob123 said:


> The sad part is, I have often joked that I learned most of class topics during Boy Scouts first-aid training...



I'll definately agree with that. Splinting, "hurry cases," and identification/initial treatment of plenty of other situations.


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## JPINFV (Feb 15, 2008)

JPINFV said:


> Did the course cover Sterling's Effect



Note: That should be Starling's Effect.


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## Outbac1 (Feb 15, 2008)

Just because you are not responsible to "do" advanced interventions doesn't mean you shouldn't know about them or be able to assist in them. Eg: If you are working your garden variety cardiac arrest with a paramedic and they ask for some "BURP" can you help them? Have the next drug ready to go before its needed?  Can you pick out the possible medical history of the pt from looking at their medications? They may not always be able to tell you their history.

  120 hours isn't enough. You need that just in A & P  and pathophysiology as a place to start. Using a glucometer or getting a 3 or 12 lead ecg are not advanced skills. To raise EMS to the level of respect it deserves we have to get away from being "ambulance drivers". I believe it starts with a proper medical education.


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## JPINFV (Feb 16, 2008)

Burp? I don't think I've heard that acronym before. I doubt that it can be as stupid of an acronym as HAM [Hx Allergies Meds] though.


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## Summit (Feb 16, 2008)

My 180 hour course... after I then took IV, EKG, Bio I & II, A&P I & II, Microbio, Pathophysiology, PHTLS, and about 200 other hours of CEs, I finally felt like I had education I should have received before being allowed to practice as an EMT in the first place.

EMT-B should be a comprehensive AAS degree, not a 9 credit hour cert.

I thought for a while I had a differnet outlook because I actually had to figure out what was wrong with patients on a long transport or that I couldn't expect ALS backup all the time. Short or long transports shouldn't matter...

And it kills me that Colorado requires a mere 36 hours of CEs to renew.


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## Keith (Feb 16, 2008)

I only read through the initial post here, not most of the responces, so pardon my ignorance if I come across as a jackass.

In my opinion, if your training a basic to do basic transfers, and crap like dialysis runs and radiation runs, then yes, 120 is fine... BUT!!!!

If your on an emergency truck, doing 911 calls, specifically in a town (in MA, I dont know how everyone else works) that only has a BLS contract... then no way...

If you jump onto a 911 shift (or for some reason someone lets you), right out of the box in MA, your heads gonna spin. Im pretty sure that most people can agree with me on these points.


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## JPINFV (Feb 16, 2008)

Keith said:


> In my opinion, if your training a basic to do basic transfers, and crap like dialysis runs and radiation runs, then yes, 120 is fine... BUT!!!!



I'll agree with that. Of course those type of calls don't require an ambulance in the first place. Just a gurney, a van, and a tank of oxygen. The problem with the current system, though, is that those EMT-Bs often respond to "emergency" [nursing facility to ER transfer] calls that can run the gamut from "we can't place a foley" to "the patient is barely breathing."

To make a further note. Medical transportation shouldn't be associated with emergency service. That said, it is a vital service that should be done by people who actually care for patients. There are too many EMT-Bs that work on the ambulance as a cheap thrill and it's one of the things that both make medical transport and EMS look bad.


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## Keith (Feb 16, 2008)

JPINFV said:


> There are too many EMT-Bs that work on the ambulance as a cheap thrill and it's one of the things that both make medical transport and EMS look bad.




To evaluate in that...

When I was training for my basic, there was a medic who stopped in one day for a lecture, or something of the sort. He made a very simple statement to me, and the lass that I think about every single day...

"If you look at EMS as a job... just a 9-5, your gonna be a horrible EMT. If you don't look at this as your career, your passion, your way of life... walk out that door right now, because you'll never make it."

I live by that thought, plain as it may be, everyday... I wish more people did.


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## Outbac1 (Feb 16, 2008)

JPINFV said:


> Burp? I don't think I've heard that acronym before. I doubt that it can be as stupid of an acronym as HAM [Hx Allergies Meds] though.



So what is it?
 I'll be back Sun. night to look for the answer.

Summit 
Sounds like you take your job really seriously. Good for you.


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## VentMedic (Feb 16, 2008)

Keith said:


> , and crap like dialysis runs and radiation runs, then yes, 120 is fine... BUT!!!!



quote by JPINFV


> I'll agree with that. Of course those type of calls don't require an ambulance in the first place. Just a gurney, a van, and a tank of oxygen. The problem with the current system, though, is that those EMT-Bs often respond to "emergency" [nursing facility to ER transfer] calls that can run the gamut from "we can't place a foley" to "the patient is barely breathing."



You next statement contradicts the above quote:


> To make a further note. Medical transportation shouldn't be associated with emergency service. That said, it is a vital service that should be done by people who actually care for patients.



And this contradicts Keith's next post:


> "If you look at EMS as a job... just a 9-5, your gonna be a horrible EMT. If you don't look at this as your career, your passion, your way of life... walk out that door right now, because you'll never make it."
> 
> I live by that thought, plain as it may be, everyday... I wish more people did.




Do either of you have enough experience with either dialysis or radiation patients to understand what their disease process involves or that they are human beings that deserve not to be called "crap".   For the nursing home patient, you are blowing off a whole set of disease processes by just identifying by a "skill" such as "inserting a foley catheter" without realizing why that foley is important and the consequences of repeated attempts or what happens if it is not inserted.   

The dialysis patient is probably the one transfer patient that can go bad very quickly either before or after dialysis.   Have you ever read their medical history, looked at their lab work or assessed their heart and lung sounds?   The dialysis patient may be sicker than 90% of the 911 calls you get.  

They do require assessing which EMT-Bs are capable of doing. But if an EMT or Paramedic insists on categorizing these patients as "crap" runs, it sends a bad message to younger EMTs or Paramedics and these patients may not get the proper assessment or _attitude_ in the back of a truck.   There are definitely reasons why some dialysis patients go by ambulance and some go by a community transfer truck. It is unfortunate that too many EMTs and Paramedic blow this patients off as "crap" and never look at the medical history or assessment of these patients to understand that reason.  And no, it is not just a "fraud thing" cooked up by the doctors and ambulance companies. If an ambulance service did all the dialysis transfers in a community, there wouldn't be time for anyone else and there probably are not enough ALS and BLS ambulances in a city to do the job.  A smaller moderate sized dialysis center can see well over 100 patients in a day.  

I can definitely see a need for more education for both EMT and EMT-P in A&P and Disease Processes/Pathology.  Maybe there should be a clinical rotation through a dialysis center so EMS students can get a chance to read very complex medical histories, learn to take BPs, avoid damaging the shunt, and see many different vascular access ports that could be useful in ALS as well.  You could get the opportunity to see many complex disease processes in just one patient. 

As far as radiation, have you ever known a woman who had to go through that for breast cancer 2 treatments per day?  And then, after the second treatment they must call a cab for the ride home because they are just drained physically and emotionally.  Unfortunately, they do not qualify for an ambulance because they are usually younger and not as many body systems are affected...yet.   For an older pt or someone who is in an advanced stage of the disease can not and should not have to "call a cab".  Are you qualified to "stage cancer"?

While there should be a system in place to not use the 911 ambulances, these patients deserve at the very least someone who can assess, initiate treatment and know where to divert to if the patient warrants it.  There should be an EMT-B or someone with the equivalent even on the community transfer vans.


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## JPINFV (Feb 16, 2008)

VentMedic said:


> Do either of you have enough experience with either dialysis or radiation patients to understand what their disease process involves or that they are human beings that deserve not to be called "crap".   For the nursing home patient, you are blowing off a whole set of disease processes by just identifying by a "skill" such as "inserting a foley catheter" without realizing why that foley is important and the consequences of repeated attempts or what happens if it is not inserted.



I think you misread the purpose of the post. I don't believe that the person driving a patient to the dialysis clinic needs to know all too terribly enough about medicine to accomplish that. This is similar to a transport tech in a hospital. They need to know where the patient needs to go and that the patient is stable for a non-monitored transport. Anything else is gravy. My entire post was about getting providers who look at providing transport as *their job* and not as something they have to put up with because they're on an ambulance. 

The example of the foley cath was used for a varying degree of "emergency" calls. Is it important? No doubt, but the crew transporting such a patient to the hospital isn't going to exactly be doing much either during a transport. That was contrasted with a call that should have been a 911 call, yet nursing homes constantly decide to wait 20-30 minutes by calling the local friendly interfacility transport company. 





> The dialysis patient is probably the one transfer patient that can go bad very quickly either before or after dialysis.   Have you ever read their medical history, looked at their lab work or assessed their heart and lung sounds?   The dialysis patient may be sicker than 90% of the 911 calls you get.


When I was doing dialysis transports we were lucky to get anything more than a face sheet unless lab values were going to or from the clinic. A patient history was completely dependent on if such a history was provided on the face sheet. That varied from SNF to SNF. Yes, they might be sicker, but if they're going to dialysis probably dialysis is what they need.



> They do require assessing which EMT-Bs are capable of doing. But if an EMT or Paramedic insists on categorizing these patients as "crap" runs, it sends a bad message to younger EMTs or Paramedics and these patients may not get the proper assessment or _attitude_ in the back of a truck.   There are definitely reasons why some dialysis patients go by ambulance and some go by a community transfer truck.


Where I worked, non-ambulance, gurney vans were virtually non-existent. I think I can count on one hand the amount of times I had seen one, and that was always near the outskirts of the county. Furthermore, it's my understanding that medi-care doesn't reimburse such transports, hence why one of the necessity criteria is to not be able to transfer to/from a wheelchair under ones own power. So, the sickest of the sick as well as the most stable all went via ambulance if they were not in a wheel chair.  


> It is unfortunate that too many EMTs and Paramedic blow this patients off as "crap" and never look at the medical history or assessment of these patients to understand that reason.  And no, it is not just a "fraud thing" cooked up by the doctors and ambulance companies. If an ambulance service did all the dialysis transfers in a community, there wouldn't be time for anyone else and there probably are not enough ALS and BLS ambulances in a city to do the job.  A smaller moderate sized dialysis center can see well over 100 patients in a day.


And that's why there's 8 major ambulance companies in Orange County, CA alone with at least one company running 80k calls a year with over half being non-emergent transports. Mind you, that included hospital discharges, of which, a high number of BLS discharges also really don't need a BLS crew. Some do, but definitely not all. 



> I can definitely see a need for more education for both EMT and EMT-P in A&P and Disease Processes/Pathology.  Maybe there should be a clinical rotation through a dialysis center so EMS students can get a chance to read very complex medical histories, learn to take BPs, avoid damaging the shunt, and see many different vascular access ports that could be useful in ALS as well.  You could get the opportunity to see many complex disease processes in just one patient.


I can get behind this idea.


> As far as radiation, have you ever known a woman who had to go through that for breast cancer 2 treatments per day?  And then, after the second treatment they must call a cab for the ride home because they are just drained physically and emotionally.  Unfortunately, they do not qualify for an ambulance because they are usually younger and not as many body systems are affected...yet.   For an older pt or someone who is in an advanced stage of the disease can not and should not have to "call a cab".  Are you qualified to "stage cancer"?


No, that's the job of the health care providers who sign the "certificate of necessity" job (MD/DO, PA, NP, RN, discharge planner). If the patient doesn't meet an established criteria, there is a place for a narrative to justify the transport. As an ambulance provider, my job is to go where I'm dispatcher, transport to where I'm dispatched to transport too [provider the patient is stable. I have no qualms about rerouting to the nearest hospital], evaluate the patient, and provider competent care both medically and customer service  [to both the facilities and the patient] wise. There are plenty of providers who fail at one or both of those points though.


> While there should be a system in place to not use the 911 ambulances, these patients deserve at the very least someone who can assess, initiate treatment and know where to divert to if the patient warrants it.  There should be an EMT-B or someone with the equivalent even on the community transfer vans.



I do believe that a different title should be selected then because the EMT-B program is currently geared towards acute diseases and not chronic diseases.  It shouldn't be a stop for a basic looking to get their year in prior to medic school though. As far as "initiating treatment," what sort of treatment are you looking at basics starting outside of oxygen, PPV, simple airway adjuncts, CPR, and driving?


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## VentMedic (Feb 16, 2008)

JPINFV, I'm not posting this to be disrespectful to you or argumentative.  But, you have presented a opening for me to respond as I think labeling patients as "crap" or "BS" is something that can get any provider into difficulty as it will skew you assessment before you even see the patient.   I would hope that these labels are not being taught in EMT class.   These terms should not be part of any type of medical student's vocabulary.  Even a physician in training would be severely reprimanded in front of his/her peers if they referred to any patient with those terms. 



JPINFV said:


> I think you misread the purpose of the post. I don't believe that the person driving a patient to the dialysis clinic needs to know all too terribly enough about medicine to accomplish that. This is similar to a transport tech in a hospital. They need to know where the patient needs to go and that the patient is stable for a non-monitored transport. Anything else is gravy. My entire post was about getting providers who look at providing transport as *their job* and *not as something they have to put up with because they're on an ambulance.*



You don't honestly mean dialysis patients are something that you have to put up with because you are "on an ambulance". 




JPINFV said:


> The example of the foley cath was used for a varying degree of "emergency" calls. Is it important? No doubt, but the crew transporting such a patient to the hospital isn't going to exactly be doing much either during a transport. That was contrasted with a call that should have been a 911 call, yet nursing homes constantly decide to wait 20-30 minutes by calling the local friendly interfacility transport company.



So these patients are not worthy of at least a quick assessment? 

Nurses at NHs are caught in the middle.  If they call for a routine BLS somebody complains it should have been 911.  If they call 911, somebody complains it is just a "crap" or "BS" call.   There are also several other variables like the physician may have called ahead for a direct admit with a known diagnosis.  This is a gray area for all providers and again the RN and EMT are caught in the middle.  There is also the issue with limited resuscitation and DNR orders.  Some BLS and ALS trucks will waste time about what to treat or not to treat while more time is wasted.   The patient has to lay there and listen to this argument wondering if they are going to get any treatment for that broken hip or if they are just a burden to the system and should be left to die.  Yes, that's dramatic but realistic and happens on a daily basis in any given city. 




JPINFV said:


> When I was doing dialysis transports we were lucky to get anything more than a face sheet unless lab values were going to or from the clinic. A patient history was completely dependent on if such a history was provided on the face sheet. That varied from SNF to SNF. Yes, they might be sicker, but if they're going to dialysis probably dialysis is what they need.



Do you rely on a face sheet on your 911 calls for a history?  Ever try physically assessing and talking to the patient? 

Yes they need dialysis but they can also be diabetics, CAD, serious electrolyte imbalances, CHF, acid-base nightmares etc.   Do you wait until they crash before you know anything about them.  Unfortunately many do wait. They then rush into the nearest ER and the only thing the EMTs or Paramedics can offer is "dialysis patient" and "I think they have kidney failure" as a history. 




JPINFV said:


> Where I worked, non-ambulance, gurney vans were virtually non-existent. I think I can count on one hand the amount of times I had seen one, and that was always near the outskirts of the county. Furthermore, it's my understanding that medi-care doesn't reimburse such transports, hence why one of the necessity criteria is to not be able to transfer to/from a wheelchair under ones own power. So, the sickest of the sick as well as the most stable all went via ambulance if they were not in a wheel chair.
> 
> And that's why there's 8 major ambulance companies in Orange County, CA alone with at least one company running 80k calls a year with over half being non-emergent transports. Mind you, that included hospital discharges, of which, a high number of BLS discharges also really don't need a BLS crew. Some do, but definitely not all.



And still, I don't believe you actually know how many patients are admitted or discharged from any one hospital either as inpatient or outpatient in one day.  In a large city there are definitely well over a 1000 patients needing dialysis 3x/week.  That doesn't include all the other therapies including rehab for the quads and paras.  Many hospital systems have their own transport vans as courtesy.  Ambulances only transport a very small percentage of these patients. 



JPINFV said:


> No, that's the job of the health care providers who sign the "certificate of necessity" job (MD/DO, PA, NP, RN, discharge planner). If the patient doesn't meet an established criteria, there is a place for a narrative to justify the transport. As an ambulance provider, my job is to go where I'm dispatcher, transport to where I'm dispatched to transport too [provider the patient is stable. I have no qualms about rerouting to the nearest hospital], evaluate the patient, and provider competent care both medically and customer service  [to both the facilities and the patient] wise. There are plenty of providers who fail at one or both of those points though.



So why do EMTs and Paramedics still insist on using the terms "crap" and "BS" when referring to a transfer patient.   If somebody with more than 120 or even 1000 hours of training has signed the certificate of necessity, do you not think there might exist a reason?  They are accountable for their actions.  You posted that you only know what is on the transfer sheet which may be only one general diagnosis. 




JPINFV said:


> I do believe that a different title should be selected then because the EMT-B program is currently geared towards acute diseases and not chronic diseases.  It shouldn't be a stop for a basic looking to get their year in prior to medic school though. As far as "initiating treatment," what sort of treatment are you looking at basics starting outside of oxygen, PPV, simple airway adjuncts, CPR, and driving?



Chronic does not mean they don't have acute problems.  That is the problem with labels.  It gives one a misconception about potential problems that are occurring and skews an assessment.    Maybe the EMT-B should also complete the CNA cert to have a more rounded view of various patients and not just the "exciting" stuff.  At least 80 hours in a SNF or Subacute in addition to the EMT-B clinicals might give one a different perspective on patient care and the system. 



> As far as "initiating treatment," what sort of treatment are you looking at basics starting outside of oxygen, PPV, simple airway adjuncts, CPR,



I consider that initiating treatment.  Assessment of vitals should also be included but is often forgotten on these "so called by many negative terms"  routine transports. 

I can also tell you that when an RN, RRT or Hospitalist(MD) hears about a dialysis patient coming into the ED or being admitted, they may also say "crap" but not because the patient is "routine".  These professionals know how fragile these patients are, how closely they must be monitored, how easy they can go bad, how extensive their histories are and how many meds they must try to regulate.

These are patients with individual needs.  They should not be viewed by an "insurance status" or labeled by disease or type of disease.   Even though your patch says "Emergency" on it, patient care of all aspects must be respected.  When did they stop teaching that in EMT or Paramedic school?


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## JPINFV (Feb 16, 2008)

VentMedic said:


> JPINFV, I'm not posting this to be disrespectful to you or argumentative.  But, you have presented a opening for me to respond as I think labeling patients as "crap" or "BS" is something that can get any provider into difficulty as it will skew you assessment before you even see the patient.   I would hope that these labels are not being taught in EMT class.   These terms should not be part of any type of medical student's vocabulary.  Even a physician in training would be severely reprimanded in front of his/her peers if they referred to any patient with those terms.


I don't think that you're trying to be argumentative or disrespectful. I hope you don't think that I'm doing the same. It's a discussion and things go back and forth. 

The labels themselves aren't being taught, but I would place money that anyone who has worked in the field has been exposed to people who carried that attitude. There are, unfortunately, plenty of providers who treat non-emergent transports as the bane of their existence and do treat non-emergent patients like crap. It's not right, but given the current situation regarding EMS and ambulance company operations, unfortunately, doesn't seem like it's going to change any time soon.




> You don't honestly mean dialysis patients are something that you have to put up with because you are "on an ambulance".


Me, personally? No. I can't say that that didn't apply to some of my coworkers though. I honestly can't say that I was overjoyed when the 5th interfacility dispatch came over the pager in less than 4 hours into a shift, but that is a part of the job and if I didn't like it enough that it affected my patient care, then I know where the door is. Again, that doesn't go to say that there aren't ambulance personal who let these things affect how they act towards a patient.



> So these patients are not worthy of at least a quick assessment?


Do patients going to dialysis clincs via wheel chair van receive a quick examination past a look over?


> Nurses at NHs are caught in the middle.  If they call for a routine BLS somebody complains it should have been 911.  If they call 911, somebody complains it is just a "crap" or "BS" call.   There are also several other variables like the physician may have called ahead for a direct admit with a known diagnosis.  This is a gray area for all providers and again the RN and EMT are caught in the middle.  There is also the issue with limited resuscitation and DNR orders.  Some BLS and ALS trucks will waste time about what to treat or not to treat while more time is wasted.   The patient has to lay there and listen to this argument wondering if they are going to get any treatment for that broken hip or if they are just a burden to the system and should be left to die.  Yes, that's dramatic but realistic and happens on a daily basis in any given city.


I won't argue that it's unrealistic. Personally, if I'm on a call that should have been a 911 call then I don't believe that I have enough time to hash out who to call and when on scene. The only exception [which I've never experienced, but have heard first hand stories of it happening] is if I do need paramedics and the nursing home staff is preventing me from making a 911 call for paramedics. Of course Orange County has the insanity of only having paramedics with the fire department, so it's either call for a BLS transport or call 911. There is, litterally, no other option short of arranging a CCT with an RN. Of course even in that case, it takes 1 person to call 911. The other person on the ambulance should be caring for the patient anyways. 

As far as being caught in the middle, there are obvious times when 911 should be contacted. I'm not talking about getting my panties in a bunch because a patient with hx of a-fib is being sent BLS and has an irregular pulse rate. The patient that's breathing 40 times a minute with accessory muscle use and is now unresponsive without a DNR, though, is a completely different story. 

As far as the interplay between the nursing home staff and the patient's PMD, I've had a chance to witness that first hand, but even then, when push came to shove [the patient was very hypertensive [210/70], as well as running a pretty decent temperature], the RN released the patient for transport [the facility was trying to contact the PMD when we arrived with a discharge. We offered to wait around for a few minutes since we were already on scene. The discharge was completed, though, before we offered to help].



> Do you rely on a face sheet on your 911 calls for a history?  Ever try physically assessing and talking to the patient?
> 
> 
> Yes they need dialysis but they can also be diabetics, CAD, serious electrolyte imbalances, CHF, acid-base nightmares etc.   Do you wait until they crash before you know anything about them.  Unfortunately many do wait. They then rush into the nearest ER and the only thing the EMTs or Paramedics can offer is "dialysis patient" and "I think they have kidney failure" as a history.


Yes, if the patient can talk. Even then, there are plenty of patient's in SNFs that do not know their full medical history. The patient, face sheet, and any accompanying H/P are all sources for a patient's medical history. 



> And still, I don't believe you actually know how many patients are admitted or discharged from any one hospital either as inpatient or outpatient in one day.  In a large city there are definitely well over a 1000 patients needing dialysis 3x/week.  That doesn't include all the other therapies including rehab for the quads and paras.  Many hospital systems have their own transport vans as courtesy.  Ambulances only transport a very small percentage of these patients.


I guess the area I worked in is pretty screwed up though [not meant tongue in cheek]. I'm trying to think if I can remember any hospital that ran their own transportation. Just because I don't know if they did doesn't mean that it didn't happen. Again, my area had a very healthy non-emergent ambulance transport environment utilizing both wheel chair vans and ambulances. There was no middle ground between those, though. If a patient couldn't sit in a wheel chair, then they, by default, went by ambulance. Of course, not every patient going to dialysis arrived via ambulance, or even ambulance and wheel chair van. You still had, though, ambulances showing up at private residences , board and cares [assisted living out of a private residence], and assisted living places 3 times a week to transport a patient to dialysis. 



> So why do EMTs and Paramedics still insist on using the terms "crap" and "BS" when referring to a transfer patient.   If somebody with more than 120 or even 1000 hours of training has signed the certificate of necessity, do you not think there might exist a reason?  They are accountable for their actions.  You posted that you only know what is on the transfer sheet which may be only one general diagnosis.


First, I don't think that all of the reasons on a certificate of necessity reflect a need for an ambulance over a gurney van. Gurney vans, though, aren't a covered means of transportation. 

Second, even the federal government is saying that up to 25% of non-emergent transports [from 2002, but the report was released last year] do not actually meet the definition of medical necessity.
http://www.emsresponder.com/print/Emergency--Medical-Services/Multimillion-Mistakes/1$5006

Third, is a crew transporting a patient with dementia or other chronic disease that makes a patient confused supposed to argue with the nursing staff for a history and physical? I've had a hard enough time getting a report from staff for an emergency call and, god forbid, if I actually ask for a copy of the MAR instead of a med list [which we have been requested to do by RNs at the receiving hospitals]. Now that crew is delaying transport, which, especially if the transports are running behind, is going to have a ripple affect through out all of the dialysis clinics as they find that they can't clear chairs for their next patient thereby pushing everyone's appointment behind.  


[split up due to character limit]


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## JPINFV (Feb 16, 2008)

> Chronic does not mean they don't have acute problems.  That is the problem with labels.  It gives one a misconception about potential problems that are occurring and skews an assessment.    Maybe the EMT-B should also complete the CNA cert to have a more rounded view of various patients and not just the "exciting" stuff.  At least 80 hours in a SNF or Subacute in addition to the EMT-B clinicals might give one a different perspective on patient care and the system.


You're absolutely right, chronic does not equate to not having any acute problems. But chronic problems can also provide cover for acute problems. Who says that a patient with a history of renal problems, diabetes, dementia  isn't extra confused today because of a problem with the first two? A BLS crew that isn't acquainted enough with a patient to truly know the patient's baseline is going to have to accept the care giver's word [RN or otherwise] that the patient's current state is normal. 

Personally, I'd like to see some time in SNFs just to understand what a nursing home staff has to do to arrange a transport, especially an immediate/emergency transport.  



> I consider that initiating treatment.  Assessment of vitals should also be included but is often forgotten on these "so called by many negative terms"  routine transports.


I'll ask the same question again that I asked earlier in this post. Does a wheel chair van driver do vitals? I'm not saying that vitals shouldn't be done on any routine transport, but I don't believe that all routine transports done by ambulance necessarily need an ambulance. 


> I can also tell you that when an RN, RRT or Hospitalist(MD) hears about a dialysis patient coming into the ED or being admitted, they may also say "crap" but not because the patient is "routine".  These professionals know how fragile these patients are, how closely they must be monitored, how easy they can go bad, how extensive their histories are and how many meds they must try to regulate.


Then should we do away with wheel chair vans that transport patients with similar histories, but aren't bed bound?


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## VentMedic (Feb 16, 2008)

JPINFV said:


> Then should we do away with wheel chair vans that transport patients with similar histories, but aren't bed bound?



No, but I do believe the drivers should have some medical training either CNA or EMT.  The EMT trained driver would be able to recognize a problem hopefully and divert quickly if needed.   The majority of our outpatients do arrive by some type of transport with a non medical person.  Many times have been delivered patients that are too unstable for dialysis but are left in the waiting area to code.   I consider it a great day if I only work one code or Rapid Response Team call in the dialysis center.


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## Aileana (Feb 17, 2008)

Outbac1 said:


> To answer TKO. Yes we have EMR's. But they are called MFR's ( medical first responder not emergency medical responder). Is there another way we can mix up the alphabet to say the same thing so we can become more confused? Our MFR's are volunteer, mostly with fire depts. and may be first on scene to provide initial care.  Some depts. operate that they go to all code 1 medical calls and others at paramedics request. For us we only have two codes. Code 1 is with lights and siren and code 2 without. They have about two weeks of training, can start an assessment, give O2, take a bgl and give oral glucose. I'll have to check to see if they can give ASA and nitro. They also extracate backboard and collar. They do NOT transport.
> We are getting more ACP's as more medics upgrade but they are still scarce in the rural areas. At our base we have 26 medics. 10 ACP, 9 PCP, 7 ICP. The ICP was a stopgap measure from about 10 years ago to get als when there were few ACP's.  They can do IV's, intubate dead people, give morpine and valium, and in an arrest give epi, atropine, and lidocaine.That's about it. The province stopped registering ICP's about 6 years ago.  So there are no new ones. The only exception is if an American EMT-P wants to get registered here they will temporally register them as an ICP. They then have one year to write the provincial exam. If they pass, (and they do), they get registered as an ACP.
> Now out of curiosity what do various people get paid for their registration level? How many hours in your avg work week?
> Here a new PCP gets $17.50 hr, with 5 years exp. $19.90. An ACP starts at $21.50 and with 5 years exp. $24.50. I might be out a few cents as I haven't got my book handy. We work an avg. 42 hour week plus overtime if you want and there is always lots. We do mostly 12 hour shifts in a two day two night four days off rotation. Some of the quieter rural bases work 24 on 72 off. Our contract is up soon and its nice to know whats around.
> ...



In Ontario, we have MFR courses, but they aren't used in EMS as far as I know (minimum for employment is PCP). Our PCPs can give nitro, ASA, glucagon, oral glucose, ventolin, and epi, do and interpret 4-leads (and 12-leads in some regions), S-AED (don't think they can go manual, but I'm not entirely sure), take BGLs, and some other stuff. Our ACP's do all that plus narcotics and about 20 other drugs, intubations, IVs and IOs, crics, and some other stuff. The region I worked out of normally had split trucks (a PCP paired with an ACP). 

I didn't realize that the EMT program in the states was only 120 hours. Not sure how all of the essential information can be learned in that sort of time. Its a 2 year college program here. I have just applied for it now, and am hoping to get in (2000 applicants, and 70 seats at my first choice ). 

We normally work 12 hour shifts, on a rotating schedule (few nights, few off, few days, few off etc.) where I ride out of, and PCPs start around $20/hour, and go up to about $25/hour. ACPs start around $30/hour as far as I know, but not sure what they get up to.


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## Outbac1 (Feb 17, 2008)

Aileana

   Our MFRs are volunteer. Mostly with FD. 

   Our PCPs and ACPs do the same stuff. We just don't get paid the same, but we are working on it.  

  Yeah I was surprised that their Basics only had 120 hours or so as well. About what our MFRs have. I thought when we (PAC) created the PCP etc we were just catching up to the US. I didn't think we went right on by.


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## BEorP (Aug 20, 2008)

Aileana said:


> In Ontario, we have MFR courses, but they aren't used in EMS as far as I know (minimum for employment is PCP). Our PCPs can give nitro, ASA, glucagon, oral glucose, ventolin, and epi, do and interpret 4-leads (and 12-leads in some regions), S-AED (don't think they can go manual, but I'm not entirely sure), take BGLs, and some other stuff. Our ACP's do all that plus narcotics and about 20 other drugs, intubations, IVs and IOs, crics, and some other stuff. The region I worked out of normally had split trucks (a PCP paired with an ACP).
> 
> I didn't realize that the EMT program in the states was only 120 hours. Not sure how all of the essential information can be learned in that sort of time. Its a 2 year college program here. I have just applied for it now, and am hoping to get in (2000 applicants, and 70 seats at my first choice ).
> 
> We normally work 12 hour shifts, on a rotating schedule (few nights, few off, few days, few off etc.) where I ride out of, and PCPs start around $20/hour, and go up to about $25/hour. ACPs start around $30/hour as far as I know, but not sure what they get up to.



Sorry to bring back an old thread, but I wanted to offer some additional information. Additional PCP skills in Ontario, depending on region, _may_ include: IVs, D50, gravol, benadryl, airway devices such as the Combitube or King LT, and manual defibrillation. 

I believe that generally in Ontario the PCP wage to start is around $30 an hour or at least in the high $20 range. I do not know of a service that pays only $20 an hour in Ontario in 2008.


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