# Finally ! Someone who cares about BLS and EMT's



## eynonqrs (Dec 20, 2009)

The other day I was reading the JEMS article about BLS being an afterthought. I can't agree more with it. I have been in this field for almost 18 years now, and I have seen alot of changes. For one, they way the state that I am from [PA] is teaching EMT's is horrible.. this is no joke, for a stubbed toe, call ALS. WTH ???? New EMT's that I see are horrible, they have no skills. When I took my EMT, we were shown the proper way to do stuff and we had to observe in the Emergency Room at a hospital for so many hours. Yet, to be a paramedic in this state you need only be an EMT for 6 monts. How can one be a good paramedic when one is a lousy EMT? Heck, when I stared in working for a paid service in 95, I had to do so much ride along time and prove that I had the skills, same held true for my volunteer service. The county that I reside in is messed up, too. They dispatch ALS for about everything. Since when is a high temp in adults ALS ? I can understand why for Peds for the risk of seziures. Since when has a hop FX become ALS ? I can go on and on about it... The EMT can't get no skills because when they get there [the BLS rig] all they are doing is getiing a stretcher and that is it. The county that I am from ALS is ran by three private services, and there have been times where there is no ALS. Or there has been one ALS unit that was available and got sent to the middle of nowhere for a High Temp or Nose Bleed. What if someone called 911 and needed ALS for a true critical call and died beacuse of it ??? Most hospitals in the county where I am from are in the 10 to 15 min range, unless you are in the rural sections. It truly amazes me that the hospital ER staff will :censored::censored::censored::censored::censored: if you come in BLS with a fracture... "oh, why didn't you start an IV ?" well they are too dam lazy to do it themselves. They only way EMT's get any skills is if you work or volunteer in a rural area where ALS is 20 to 30 min away. Hell, I say why do we need fancy BLS ambulances with all that equipment that we are required to carry that we don't use ? I say BLS should go back to the days of the caddie ambulances and all you needed was FA/CPR. Sorry about the rambling, but this article makes sense and it makes me angry that no one has faith in EMT's or want's to give any time or effort to make them work on thier skills !


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## Lifeguards For Life (Dec 20, 2009)

eynonqrs said:


> The other day I was reading the JEMS article about BLS being an afterthought. I can't agree more with it. I have been in this field for almost 18 years now, and I have seen alot of changes. For one, they way the state that I am from [PA] is teaching EMT's is horrible.. this is no joke, for a stubbed toe, call ALS. WTH ???? New EMT's that I see are horrible, they have no skills. When I took my EMT, we were shown the proper way to do stuff and we had to observe in the Emergency Room at a hospital for so many hours. Yet, to be a paramedic in this state you need only be an EMT for 6 monts. How can one be a good paramedic when one is a lousy EMT? Heck, when I stared in working for a paid service in 95, I had to do so much ride along time and prove that I had the skills, same held true for my volunteer service. The county that I reside in is messed up, too. They dispatch ALS for about everything. Since when is a high temp in adults ALS ? I can understand why for Peds for the risk of seziures. Since when has a hop FX become ALS ? I can go on and on about it... The EMT can't get no skills because when they get there [the BLS rig] all they are doing is getiing a stretcher and that is it. The county that I am from ALS is ran by three private services, and there have been times where there is no ALS. Or there has been one ALS unit that was available and got sent to the middle of nowhere for a High Temp or Nose Bleed. What if someone called 911 and needed ALS for a true critical call and died beacuse of it ??? Most hospitals in the county where I am from are in the 10 to 15 min range, unless you are in the rural sections. It truly amazes me that the hospital ER staff will :censored::censored::censored::censored::censored: if you come in BLS with a fracture... "oh, why didn't you start an IV ?" well they are too dam lazy to do it themselves. They only way EMT's get any skills is if you work or volunteer in a rural area where ALS is 20 to 30 min away. Hell, I say why do we need fancy BLS ambulances with all that equipment that we are required to carry that we don't use ? I say BLS should go back to the days of the caddie ambulances and all you needed was FA/CPR. Sorry about the rambling, but this article makes sense and it makes me angry that no one has faith in EMT's or want's to give any time or effort to make them work on thier skills !



The "ALS/BLS" (where else in medicine is there ALS and BLS? Is there such a thing as a BLS physician?) divide is simple. Is this patient going to see a physician in an emergency room? Then the patient deserves at least an assessment by a paramedic due to the extreme difference in education, training, diagnostic tools and interventions between basics and paramedics.

Hip fracture patients and adults with high fevers can not be accomodated properly at the Basic level. The hip fracture patient may be best suited with meds for pain managment, the adult with a high fever may benefit from intravenous fluids and/ or medications.


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## zmedic (Dec 20, 2009)

I think fractures should be ALS. It's not about the ER not wanting to start IVs. It's about the fact that giving pain meds in the field for fractures is really one of the few cases where EMS can make people feel a lot better on the way to the hospital.


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## JPINFV (Dec 20, 2009)

eynonqrs said:


> They dispatch ALS for about everything. Since when is a high temp in adults ALS ? I can understand why for Peds for the risk of seziures. Since when has a hop FX become ALS ?



Callers lie. Sepsis. Pain control. 


Also, as far as experience, why don't other health care fields require work at a lower level? It's strange how the vast majority of my fellow students don't have any certifications or licenses prior to starting med school.


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## Lifeguards For Life (Dec 20, 2009)

JPINFV said:


> Callers lie. Sepsis. Pain control.
> 
> 
> Also, as far as experience, why don't other health care fields require work at a lower level? It's strange how the vast majority of my fellow students don't have any certifications or licenses prior to starting med school.



just out of curiosity, do you feel your training and experience as an EMT give you an upper hand in med school?

(not trying to pick on you, just wondering)


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## JPINFV (Dec 20, 2009)

Maybe a little bit in the class that covers physcial exams and the like (Essentials of Clinical Medicine), but it's equally a liability. On one hand, I'm more comfortable working with standardized patients and obtaining a history and physical. On the other hand, I'm just as likely to go off on something (e.g. had an SP comment that a BP was lower than normal and I was reassuring him that it was still a good BP. He commented afterwards that he wanted to tell me to move on since the encounters have a time limit and I was eating up precious time).


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## Lifeguards For Life (Dec 20, 2009)

*is this the article you mention?*

http://www.jems.com/news_and_articles/articles/jems/3412/back_to_basics.html


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## eynonqrs (Dec 20, 2009)

Lifeguards For Life said:


> http://www.jems.com/news_and_articles/articles/jems/3412/back_to_basics.html



Yes it is, thank you for the link. I agree with the article 100%.


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## JPINFV (Dec 20, 2009)

To bad the article is mostly junk. The only reasonable valid issue is paramedic saturation, and even then, that's when you have 5-6 paramedics responding to a call, not just straight up having 2 paramedics respond to all 911 calls.


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## Aidey (Dec 20, 2009)

JPINFV said:


> Callers lie. Sepsis. Pain control.
> 
> 
> Also, as far as experience, why don't other health care fields require work at a lower level? It's strange how the vast majority of my fellow students don't have any certifications or licenses prior to starting med school.



Exactaly. RNs aren't required to spend time as CNAs or LPNs before they can go to RN school. Paramedic schools could be easily modified to include all of the curriculum that the EMT B class cover. 




Lifeguards For Life said:


> just out of curiosity, do you feel your training and experience as an EMT give you an upper hand in med school?
> 
> (not trying to pick on you, just wondering)



I've known a couple people who are in med school, or are planning on applying. Previous patient care experience can give you "brownie points" at some schools. Some PA schools also require a certain number of patient contact hours before you can apply (The school my co worker just got into does at least).



I will agree with the ideas that we need to start at the beginning and then move towards the advanced, and we need to make sure we are remembering our assessment skills, but this article is just going to inflame the BLS vs ALS debate even more. 

As stupid as it sounds, you don't know why the caller stubbed their toe until you get there. Is it because they became dizzy and lost their balance, or suddenly lost sight in one eye? Fevers and fractures are also two things that definitely deserve "ALS" assessment and probably intervention. The pt has a fever for a reason, and that underlying reason may need some serious interventions to keep the patient alive (My last "flu like symptoms" dispatch arrested on the way to the hospital. The guy was 40).


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## Lifeguards For Life (Dec 20, 2009)

eynonqrs said:


> Yes it is, thank you for the link. I agree with the article 100%.



what interventions would you want for a patient with a (for discussion let's say a confirmed a type II Intertrochanteric  fracture, in a 60 year old female, following a trip over a curb); BLS procedures only?


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## So. IL Medic (Dec 20, 2009)

Lifeguards For Life said:


> (where else in medicine is there ALS and BLS? Is there such a thing as a BLS physician?)QUOTE]
> 
> Yep. It's called a P.A.


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## So. IL Medic (Dec 20, 2009)

JPINFV said:


> Callers lie. Sepsis. Pain control.
> 
> 
> Also, as far as experience, why don't other health care fields require work at a lower level? It's strange how the vast majority of my fellow students don't have any certifications or licenses prior to starting med school.



Around here, all nursing students must start as CNAs now.


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## Aidey (Dec 20, 2009)

> True BLS skills—from patient positioning and vital signs to providing oxygen, from bandaging and splinting to placement of airway adjuncts, from the physical examination to spinal immobilization—should ideally be performed by BLS personnel whenever possible, leaving the ALS personnel to perform ALS interventions and formulate a treatment plan based on a diagnostic impression.



This actually makes me mad, now that I've read it again. It makes it sound like BLS skills are below Paramedics and we just need to focus on the major stuff. It also makes it sound like Paramedics are one-hit-wonders only good for interventions. 

What paramedic out there is going to perform an intervention without doing any of those things themselves? How can I form a diagnostic impression when physically examining the pt is apparently my partner's job and not mine. No offense to EMTs but Paramedics are taught more advanced physical assessment techniques, and in some cases an EMT may not know something they are looking at is significant. 

I'm going to be the one writing the report and giving report to the hospital. Even if I don't perform an exam or procedure myself, you can be sure I'm watching it if at all possible. Even with something like an oral airway. If an oral airway is going in, chances are the pt is getting intubated. Putting in or watching the oral airway be put in gives me an additional chance to look at the pts oral anatomy and helps me decide what tools I will need. 

That all being said, I trust my partner and I have a good understanding of his knowledge base. He understands that even though I trust him, I still like to see things for myself. If he finds something strange he will get my opinion, and it's not at all uncommon for me to ask his opinion when I find something strange. Or ask his opinion on how to describe something. At the same time though, if my partner palpates something and the patient screams and he states he feels crepitice, I'm not going to poke at it too.


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## Lifeguards For Life (Dec 20, 2009)

Aidey said:


> This actually makes me mad, now that I've read it again. It makes it sound like BLS skills are below Paramedics and we just need to focus on the major stuff. It also makes it sound like Paramedics are one-hit-wonders only good for interventions.
> 
> What paramedic out there is going to perform an intervention without doing any of those things themselves? How can I form a diagnostic impression when physically examining the pt is apparently my partner's job and not mine. No offense to EMTs but Paramedics are taught more advanced physical assessment techniques, and in some cases an EMT may not know something they are looking at is significant.
> 
> ...



the article did not seem to acknowledge that paramedics are EMT's as well


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## eynonqrs (Dec 20, 2009)

Lifeguards For Life said:


> what interventions would you want for a patient with a (for discussion let's say a confirmed a type II Intertrochanteric  fracture, in a 60 year old female, following a trip over a curb); BLS procedures only?



BLS procedures:

I would fully immoblize pt with a c-collar, cid's, and use a scoop stretcher [they are good for hip fx's] if a scoop stretcher was not available I would use a backboard. I would also make sure the pt is secured properly to avoid movement of the leg to avoid further injury. I would constantly monitor vital signs every ten minutes as I would for any trauma pt.


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## Lifeguards For Life (Dec 20, 2009)

eynonqrs said:


> BLS procedures:
> 
> I would fully immoblize pt with a c-collar, cid's, and use a scoop stretcher [they are good for hip fx's] if a scoop stretcher was not available I would use a backboard. I would also make sure the pt is secured properly to avoid movement of the leg to avoid further injury. I would constantly monitor vital signs every ten minutes as I would for any trauma pt.




ok. your patient is in severe pain, and is scared of losing her independence, and ability to perform daily activities. Do you feel her needs may be better met by a clinician who can provide her with pain management on a (15-20 i believe you said in the original post) minute transport to definitive care?

Lets say that when you reassess her vitals she has become, tachycardic, tachypnic, hypotenisve, and has become cool, pale and diaphoretic.
People with an intertrochanteric hip fracture may become light-headed or weak or even go into shock. these hip fractures can damage blood vessels and cause bleeding inside the hip. 

Are there any ways this patient could possibly beneift from a BLS transport as opposed to an ALS transport? what patient do you feel would benefit from BLS over ALS?


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## Aidey (Dec 20, 2009)

Good luck, hopefully you will recover quickly from the concussion you get after moving her without any pain control and she whacks you with her cane/purse/pot/pan/whatever is handy. 

Ok. That was unfair, I admit it. Not all fracture patients want pain meds, but you will definitely come across those that won't even let you touch them until you've given them some pain relief.

In addition to what L4L said, the patient may have other injuries that become apparent later on. A hip fracture is definitely a distracting injury. 

You should also never believe a patient who tells you they tripped and fell until you've fully assessed them for medical reasons for the fall. 

"So what happened here today ma'am?"
"Oh I just fell over and hit the floor"
"What made you fall today?'
"Well, I started feeling funny and then I felt like someone kicked me in the chest and it knocked the wind out of me and then I just fell over" (Anyone guess what that was?)


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## daedalus (Dec 20, 2009)

Every patient that goes to the ED is eventually seen by the physician or PA. Why does EMS think that just because someone stubbed a toe, they should get seen by the lowest level provider?

Paramedics are *supposed* to be experts in prehospital medicine. They should probably be dispatched to most 911 calls.

Also, a fever is very much an "ALS" complaint. Can an EMT describe the mechanisms of fever, examine for causes, and understand the critical nature of infections in certain populations?


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## VentMedic (Dec 20, 2009)

So. IL Medic said:


> Around here, all nursing students must start as CNAs now.


 
All nursing students (in many states) can become CNAs. I have not seen any change in the legislation in the states where that is mandatory to become an RN.



So. IL Medic said:


> Lifeguards For Life said:
> 
> 
> > (where else in medicine is there ALS and BLS? Is there such a thing as a BLS physician?)QUOTE]
> ...


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## reaper (Dec 20, 2009)

Here's a hint: go talk with a trauma surgeon and ask them what injury they hate to deal with the most! Their answer will most likely be a Pelvic fracture. More people die of pelvic fx's, because they are very hard to deal with. These Pt's need proper stabilization, IV fluids, pain management and constant monitoring.

Fevers: You may worry about seizures in peds Pt's with high fevers. I worry more about adults with high fevers. An elderly pt cannot compensate for a high fever, as much as a child can. The disease process that causes fevers in an adult are much more complicated and needs someone who can preform a proper assessment on them.

No offense here, but if this is the way you think about emergency medicine after 18 years as an EMT. Then the problem is staring right at you! You gave examples of Common "BLS" calls, that are in dire need of ALS assessment. Every call you go on should have a Paramedic assessing them. Then if they deem that it can be transported by the EMT, you can transport them. 

This is what every pt should be entitled to!


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## MrBrown (Dec 20, 2009)

Why must you American's be so obsessed with your BLS vs ALS?

Here's a newsflash, BLS: American style (120 hour course and a scope of practice which consists of oxygen and an AED (local differences aside please!)) is something out of about 1990 here.  

Your BLS consists of zero medications (again, local differences aside please!), our BLS consists of at least eight different medications with no "medical control" required.

You guys get so hung up on "oh this is a BLS patient" well why? who is to say that the "BLS" patient with "abdo pain" doesn't have a pulsating AAA that's about to burst and turn him into an "ALS" patient?

Every patient is entitled to competent, thorough and knowledgable assessment and treatment of a proper, first world standard not some archaic 120 hour course flooze where the only two interventions he can possibly provide are an oxygen tank and a toaster.

Now, let's look at the much hearalded EMS Agenda for the Future National Scope of Practice Model:

*EMT*:  Oxygen, aspirin, oral glucose, oral analegsia (tylenol?)

*A-EMT:*  IV fluid, GTN, D50, naloxone, salbutamol nebules

Now, let's look at some first world, twenty first century EMS models of "basic life support":

*NSW (Australia):* Oxygen, adrenaline, D10, glucagon, GTN, aspirin, midazolam, salbutamol, methoxyflurane, ipatropium, promethazine, fentanyl

*New Zealand:* Oxygen, methoxyflurane, entonox, aspirin, paracetamol (tylenol), zofran, salbutamol, ipatropium, glucagon, GTN

*Canada (NOCP): *Oxygen, entonox, salbutamol, aspirin, GTN, glucagon, adrenaline

Does anybody see a difference here? 

Until you guys abandon the archaic, long outdated misconception of your "BLS vs ALS" then I'm afraid the people who truly suffer will be your patients.


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## BLSBoy (Dec 20, 2009)

MrBrown said:


> Until you guys abandon the archaic, long outdated misconception of your "BLS vs ALS" then I'm afraid the people who truly suffer will be your patients.



Until we refuse to continue to allow the volunteers (at least in my area) to not only legislate themselves (nj first grade counsil) but convince the state legislators that a 120hr course is enough to "save a life", it will continue to stay like this. 

Why?

Cause this is the way its always been done.<_<


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## Aidey (Dec 20, 2009)

BLSBoy said:


> Until we refuse to continue to allow the volunteers (at least in my area) to not only legislate themselves (nj first grade counsil) but convince the state legislators that a 120hr course is enough to "save a life", it will continue to stay like this.
> 
> Why?
> 
> Cause this is the way its always been done.<_<



Not to rain on the parade even more, but it's going to be even harder to make any changes in the current political climate. Increased education means increased expenses. Tax payers are already paranoid they are being ripped off by health care, they are not going to be keen on yet another added expense. So far the argument "It works for the following X number of countries" has gotten us absolutely no where. Trying to use that argument to expand EMT education will fail miserably. I honestly don't know how we would ever be able to convince people that the change is needed because it is what is right, and not because of some grand scheme. 

I'm not saying it's right, just that that is how people are going to see it.


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## VentMedic (Dec 20, 2009)

Aidey said:


> Tax payers are paranoid they are being ripped off.


 
Ripped off?  What about Medicare and John Q Public paying $600 - $800 for a BLS "taxi" ride where the providers can only do basic first aid and O2?   

Residents in Florida and other parts of the country have been educated at election time about the difference between ALS and BLS or what the advantages of having a Paramedic on a truck can be.


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## Aidey (Dec 20, 2009)

That line should have read "Taxpayers are paranoid they are being ripped off by the current reform". I'm not sure what happened to the rest of the sentence. Oops. 

I was referring to the general feeling of getting screwed that everyone has when it comes to paying money to the government. Not anger over a specific issue, if that makes sense. 

Obviously there are some issues with the cost vs what that money is really paying for. I don't disagree at all that in every aspect of health care there disproportionate payments for the service rendered (either over payment or under payment). Many people are uneducated though, and just generally hate paying taxes, no matter what they are for.


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## VentMedic (Dec 20, 2009)

Aidey said:


> That line should have read "Taxpayers are paranoid they are being ripped off by the current reform". I'm not sure what happened to the rest of the sentence. Oops.
> 
> I was referring to the general feeling of getting screwed that everyone has when it comes to paying money to the government. Not anger over a specific issue, if that makes sense.
> 
> Obviously there are some issues with the cost vs what that money is really paying for. I don't disagree at all that in every aspect of health care there disproportionate payments for the service rendered (either over payment or under payment). Many people are uneducated though, and just generally hate paying taxes, no matter what they are for.


 
How does your state set up its tax distribution for EMS? Districts? Statute allocation? State ammendment?

How much do EMS providers know about how reimbursement works and what part of their funding comes from taxes or tax statute allocation? 

Sometimes it seems some in EMS are less educated about these issues than the public who are concerned about their taxes. In areas like AZ and FL, senior citizen groups educate each other. The AARP does a great job in some of its publications. Some of the state websites are also great at providing information for their citizens. How many EMS providers even look at their state websites to see what legislation is pending next that might affect them. 

How about just the levels for EMS providers? How many EMS providers even understand the levels within their own practice to explain to each other about getting a certification?  From some of the posts on the various EMS forums, that even seems to be an issue with the instructors not knowing or not explaining it.

Very few EMS providers know enough about tax bills or EMS to even educate each other or the public about EMS.


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## Shishkabob (Dec 20, 2009)

If you're going to diss the system, atleast get it right.  


MrBrown said:


> Your BLS consists of zero medications (again, local differences aside please!), our BLS consists of at least eight different medications with no "medical control" required.



Even WITH local differences aside, most Basics can still give a handful of drugs, none with med control required.  Epi, nitro, oxygen, ASA, Glucose, albuterol, and one other I cannot remember for the life of me because now as a medic student I can give them all.

Let me say that again... Epi and nitro.  Those aren't small drugs like Oxygen.  Is it right that they should be able to give drugs that have such a profound impact without the necessary diagnostic equipment and education?  Yes and no.  Depends on the circumstance.  




> Every patient is entitled to competent, thorough and knowledgable assessment and treatment of a proper, first world standard not some archaic 120 hour course flooze where the only two interventions he can possibly provide are an oxygen tank and a toaster.


  And this is something else that irks me.

It's one thing if you say a new grad with no further education, but QUIT combining all basics into one group and calling them uneducated.


News flash-- I'm a basic and I'm 1 class day from my final.  Daedulus is a basic.  L4L is a basic.  

Hell, JPINIV is a basic.  Is he not knowledgeable?  

Don't lump people together.  Diss the education, don't diss the people receiving it.





> Now, let's look at the much hearalded EMS Agenda for the Future National Scope of Practice Model:
> 
> *EMT*:  Oxygen, aspirin, oral glucose, oral analegsia (tylenol?)
> 
> ...




Yes.  The difference is your "Basics" can start IVs.  If ours, as a whole, could start IVs, they'd be able to give more drugs.  (Don't make the assumption I'm saying give all basics ability to do IVs...)






Disclaimer-- Always for requiring more education.


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## JPINFV (Dec 20, 2009)

daedalus said:


> Every patient that goes to the ED is eventually seen by the physician or PA. Why does EMS think that just because someone stubbed a toe, they should get seen by the lowest level provider?



Two major differences. First off, the vast majority of PA's charts are going to be signed off by a physician. Second, unless you're in the middle of BFE where (rarely, but it happens) the PA is working as coverage in a single coverage ER, the response time of an emergency physician if something goes bad is going to be measured in seconds, not minutes.


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## JPINFV (Dec 20, 2009)

Linuss said:


> News flash-- I'm a basic and I'm 1 class day from my final.  Daedulus is a basic.  L4L is a basic.
> 
> Hell, JPINIV is a basic.  Is he not knowledgeable?
> 
> Don't lump people together.  Diss the education, don't diss the people receiving it.



Sure, there are plenty of knowledgable basics out there. On the other hand, you can design a scope of practice and protocol based on the cream of the crop.


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## VentMedic (Dec 20, 2009)

Linuss said:


> It's one thing if you say a new grad with no further education, but QUIT combining all basics into one group and calling them uneducated.
> 
> News flash-- I'm a basic and I'm 1 class day from my final. Daedulus is a basic. L4L is a basic.
> 
> Hell, JPINIV is a basic. Is he not knowledgeable?


 
How many of the EMTs in your service are in med school? 

How many have at least 2 semesters of real college level A&P?

Do at least 1/3 of the EMTs hold at the very least an Associates degree? If I remember correctly, there aren't that many Licensed Paramedics in TX with an Associates to where they can get the extra patch.



> Let me say that again... Epi and nitro.


 
How many states allow at least nitro to be carried by the EMT to be given and NOT just assisting the patient to take theirs?





> Yes. The difference is your "Basics" can start IVs. If ours, as a whole, could start IVs, they'd be able to give more drugs. (Don't make the assumption I'm saying give all basics ability to do IVs...)


 
Now that is a really frightening thought with the minimum hours for the EMT training. What meds to you want them to push IV if they do not have a cardiac monitor? Adenosine? Atropine? 

You are also contradicting yourself. You talk about all the PO meds and IMs you want the patient to take but yet, they have no IV or any other med to counteract the adverse effects of a med.

Medications and IVs should be left to providers to can do more than just a "skill". Just giving a med takes very little skill. It is know when and when not to and what to do if you did when you shouldn't. 

This half-arsed piece mill "skill" mentality is what has gotten EMS to this crappy mess with over 50 different certs and no consistency for Medical Directors and legislators to even determine what some can or should not do. 

You should not just expand the EMT education with 2 hours of training at a time for each little skill they feel they are "entitled" to do.


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## zmedic (Dec 20, 2009)

I think it is important to differentiate between skills that EMTs would be using on their own versus as part of an ALS ambulance. When I worked in CO I was the basic partnered with a medic. Because I had been certified to start IVs, I could do that while the medic was taking a history, drawing up meds etc. So we had the monitor, had the drugs, but if the EMT can't do the skills they basically just do vital signs while the medic has to do everything. If an EMT can start IVs and do the monitor you can run a code with a medic, an EMT and a FF to do compressions. 

With the shortage of medics and the expense of training them it makes sense to have better trained EMTs with a medic rather then trying to fund double medic trucks.


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## Shishkabob (Dec 20, 2009)

I'm on my iPhone and as such can't type out a whole reply till later tonight.  


Vent, you and I are already in almost total agreement, you're just taking what I said to be a "give basics more skills" argument, which it's not. 

Few months ago in he "Should basics get ivs" thread, we were on the Dane page.  As a general rule you should not have a skill that you can't fix if you screw up, like fluid shift balances and the like.




Were on the same page with that, Vent.  I'm just doing what I've been doing for the past year: Argue and correct anyone who lumps all providers into one catagory. Sorry, all basics aren't equal and aren't uneducated, and anyone who says the contrary is wrong and I'll argue with them.


As I said in the other reply: I'm all for more education.


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## VentMedic (Dec 20, 2009)

zmedic said:


> With the shortage of medics and the expense of training them it makes sense to have better trained EMTs with a medic rather then trying to fund double medic trucks.


 
Shortage of medics?   Expense of training?

If they went to a state community college, 40 cr/hours x $25 - $75 dollars is not that much.  Of coures it they went to a medic mill, the cost is $12K -  $20k for a few hundred hours of training.

We have more medics than we know what to do with.  Every FF and every FF applicant is a Paramedic in some parts of the country. We have no less than 6 on every scene.  If you go into almost any of our McDonalds or Burger Kings you may find 1 or 2 employees who have had their Paramedic cert for a few years while trying each year to get on at a FD along with a couple thousand others who may also be Paramedics. 

The best partnership is 2 Paramedics or Paramedic/RN so you can discuss some different approaches to patient care.


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## VentMedic (Dec 20, 2009)

Linuss said:


> As I said in the other reply: I'm all for more education.


 
Agree with you always Linuss.


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## DrParasite (Dec 20, 2009)

this discussion (as it always does) pretty much falls long certain lines: those who are medics think that EMTs can't do anything right, and every patient needs a medic JUST IN CASE they are suffering from an asymptomatic potentially ALS emergency, and EMTs who understand that most 911 calls aren't life threatening emergencies, and even those that are, they can be handled with BLS treatments until ALS arrives.

I don't think that BLS should get drugs, nor should they get IVs.  

There are stupid BLS providers.  There are stupid ALS providers.  both can screw up an assessment and both can kill a person.

Do dying people need ALS?  YES!  No one is arguing this fact.  

however, your AAA abdominal pain, does he need ALS?  well, if he hemodynamicly stable?  so what is ALS going to do aside from take a ride to the hospital?

I was taught that ALS is for acute life-threatening emergencies, where they could actually do something to resolve the problem.  

most trauma's don't need ALS (bright lights and cold steel save trauma injuries, not ALS), saline and ringers don't carry oxygen. Ensure the patient has an airway and transport to a trauma center (and if not, then call ALS or use an OPA and a BVM).  

your old guy with a fever does not need ALS.  if the guy has had a fever for the past 3 days,  waiting another hour for an IV to reverse his dehydration won't kill him.  your simple arm fracture doesn't need pain meds prehospitally.  he won't die during the 30 minute transport time to the hospital (some would argue he doesn't even need an ambulance, just take him in the car to the ED).  and for many of your dispatched BLS emergencies, all they need is a ride to the hospital (or to their doctors office), not anything do be done to the other them before they get there.

if EMS dealt with 80% of actual life threatening emergencies, then I would agree with you that everyone needs an ALS emergency.  but when that number is closer to 20% (which is pretty close to most areas), then a BLS truck is just fine.


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## DrParasite (Dec 20, 2009)

VentMedic said:


> If you go into almost any of our McDonalds or Burger Kings you may find 1 or 2 employees who have had their Paramedic cert for a few years while trying each year to get on at a FD along with a couple thousand others who may also be Paramedics.


woooooow.  after all that hard work getting your paramedic cert, you can be qualified to work at a McDonalds or Burger King?  I know there is a joke there somewhere...

every PA in the US needs hundreds if not thousands of patient contact hours before they can even apply to PA school.  most nursing programs require, or at least recommend patient contact hours.

as for doctors not needing any prior experience, that is correct.  and how many first years residents are absolutely clueless?  what about second year?  how many nurses can run circles around a first year resident?  By the third and forth year they tend to develop a good idea of what is going on, and many still go for a fellowship (another year in one specialty) before they are considered "experts."  4 years of undergrad over a broad spectrum of stuff, 4 years focused on med school solely on medicine, and they still need another 3 to 4 years before they are given the green light to operate on their own.  hmmm, imagine that, it takes them 10+  years before a doc can go from knowing nothing to an expert, and some only require 2 years (or a few months at a medic mill) to become an expert at prehospital care.  funny how that works out...


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## medichopeful (Dec 20, 2009)

DrParasite said:


> this discussion (as it always does) pretty much falls long certain lines: those who are medics think that EMTs can't do anything right, and every patient needs a medic JUST IN CASE they are suffering from an asymptomatic potentially ALS emergency, and EMTs who understand that most 911 calls aren't life threatening emergencies, and even those that are, they can be handled with BLS treatments until ALS arrives.



Why shouldn't everybody get ALS?  A person with a seemingly minor injury or illness could potentially benefit more from having ALS than they could from having BLS.  That's a hard fact to argue against.  If the patient starts to go downhill from something the EMT/Paramedic missed, who will be able to do more?  A basic?  Or a paramedic?  It's not a trick question.  EMS should NOT be about doing the bare minimum; it should be about doing what is BEST for the patient.  And ALS can do a LOT more good than BLS can.  ALS personnel can do BLS skills.  BLS personnel can NOT do ALS skills. Keep that in mind.  A paramedic could start out treatment at a BLS level, and elevate from there if needed.  A EMT-B can start out treatment at a BLS level, but after that the patient's in trouble.



> I don't think that BLS should get drugs, nor should they get IVs.



I'll completely agree with you here, except for oxygen (it's a drug) and Epi-Pens.  



> There are stupid BLS providers.  There are stupid ALS providers.  both can screw up an assessment and both can kill a person.



The paramedic will have a lesser chance of screwing an assessment up, and a greater chance of fixing it if it happens.



> Do dying people need ALS?  YES!  No one is arguing this fact.



Not everyone who calls 911 is dying.  ALS can do more than just save a life.  Think pain management.



> however, your AAA abdominal pain, does he need ALS?  well, if he hemodynamicly stable?  so what is ALS going to do aside from take a ride to the hospital?



Remember, if a paramedic can't treat a certain illness or injury, they can provide WAY more supportive treatment than a basic can.



> I was taught that ALS is for acute life-threatening emergencies, where they could actually do something to resolve the problem.



I was taught something similar, but things need to change.  Just because we are taught something does NOT mean that it is correct.



> most trauma's don't need ALS (bright lights and cold steel save trauma injuries, not ALS), saline and ringers don't carry oxygen. Ensure the patient has an airway and transport to a trauma center (and if not, then call ALS or use an OPA and a BVM).



Keep in mind what I said above.  A paramedic can do an assessment much better than an EMT-B, and may find out that that trauma that _didn't_ need ALS really did.  Also, remember that a paramedic can start out at a basic level (OPAs and BVMs), but can elevate it when needed.



> your old guy with a fever does not need ALS.  if the guy has had a fever for the past 3 days,  waiting another hour for an IV to reverse his dehydration won't kill him.



All fevers are caused by dehydration?



> your simple arm fracture doesn't need pain meds prehospitally.  he won't die during the 30 minute transport time to the hospital (some would argue he doesn't even need an ambulance, just take him in the car to the ED).



Part of patient care is patient comfort.  Though I've been lucky and I've never broken anything, I imagine it's not too comfortable.  If you're in pain, do you want to just ride to the hospital?  Car rides and ambulance rides can be bumpy.  Wouldn't you like relief of your pain ASAP?



> and for many of your dispatched BLS emergencies, all they need is a ride to the hospital (or to their doctors office), not anything do be done to the other them before they get there.
> 
> if EMS dealt with 80% of actual life threatening emergencies, then I would agree with you that everyone needs an ALS emergency.  but when that number is closer to 20% (which is pretty close to most areas), then a BLS truck is just fine.



Have a basic be the tech in the ambulance, and have the paramedic just be there if this is the case.  But have the paramedic do an assessment as well, or expand upon the basics, before making this determination.


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## medichopeful (Dec 20, 2009)

DrParasite said:


> some only require 2 years (or a few months at a medic mill) to become an expert at prehospital care.  funny how that works out...



2 years barely makes one an "expert" at medicine...


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## VentMedic (Dec 20, 2009)

DrParasite said:


> woooooow. after all that hard work getting your paramedic cert, you can be qualified to work at a McDonalds or Burger King? I know there is a joke there somewhere...


 
The Paramedic is not that difficult to get and doesn't require many "hours of training". This is why FDs have little doubt in getting all their FFs certified. The "joke is" that few want any part of medicine or want to be a Paramedic. Some would prefer to work at places that don't involve health care until they are hired on at the FD. 

Guess where that puts the EMT?



> however, your AAA abdominal pain, does he need ALS? well, if he hemodynamicly stable? so what is ALS going to do aside from take a ride to the hospital?
> 
> I was taught that ALS is for acute life-threatening emergencies, where they could actually do something to resolve the problem.
> 
> ...


 
I was wondering how long it would take before you expressed you anti-ALS viewpoints.

As I and others have told you on another forum, your remarks just illustrate why an EMT is NOT qualified to care for medical patients. *YOU* have very little to NO understanding of medicine. *YOU* attempt to glorify the EMT into something it is not because *YOU *do not want the responsibilty that comes with being a Paramedic. If *YOU* were to actually advance your education you would see just how ridiculous your statements are. It is because of EMTs like *YOU* who make such uneducated assumptions about medicine that the other EMTs who might have a clue are viewed with the same low opinions by other professionals. 

I would say *YOU* are totally clueless as to how sick some of the patients you have transported really are and have absolutely no clue as to what a difference getting fluids started a little sooner than the ED can make.


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## JPINFV (Dec 20, 2009)

DrParasite said:


> every PA in the US needs hundreds if not thousands of patient contact hours before they can even apply to PA school.  most nursing programs require, or at least recommend patient contact hours.





> Clinical experience, while preferred, is not required


http://prospective.westernu.edu/physician-assistant/requirements



> Applicants must demonstrate health care experience_ sufficient to develop an understanding of the PA profession, the health care environment, and their own aptitude for the PA profession_.  Experiences should include shadowing a PA and work and/or volunteering in which responsibilities involve fairly extensive direct patient contact.   Direct patient interaction is valued most highly by the admissions committee.  Recent successful candidates have had *hundreds *of hours of work and/or volunteer experience.  _The program does not set a minimum number of hours of health care experience._  Volunteer work is valued as highly as paid work.


emphasis added.
http://www.physicianassistant.wisc.edu/admissions.htm#criteria

Bayor University does not mention HCA at all.
http://www.bcm.edu/pap/?PMID=6194



> Prior patient contact experience is considered desirable and applicants with such experience will be given priority consideration but not to the exclusion of applicants without such experience.


http://shrp.umdnj.edu/programs/paweb/admissions/AdmisReqCASPA.html

Hyperbole much? Sorry, not all PAs need prior HCA before applying. Saying that is like saying that all medical students need HCA and research prior to applying just because the vast majority of them do. 



> as for doctors not needing any prior experience, that is correct.  and how many first years residents are absolutely clueless?  what about second year?  how many nurses can run circles around a first year resident?  By the third and forth year they tend to develop a good idea of what is going on, and many still go for a fellowship (another year in one specialty) before they are considered "experts."  4 years of undergrad over a broad spectrum of stuff, 4 years focused on med school solely on medicine, and they still need another 3 to 4 years before they are given the green light to operate on their own.  hmmm, imagine that, it takes them 10+  years before a doc can go from knowing nothing to an expert, and some only require 2 years (or a few months at a medic mill) to become an expert at prehospital care.  funny how that works out...



Are you really going to compare paramedicine to surgery? Heck, I wouldn't even compare medicine to surgery in terms of the amount of training needed. Similarly, as far as residency goes, it's not like residents go from 100% supervision to 0% supervision overnight when they graduate. Plenty of residents moonlight in double or triple coverage ERs where they are operating with less oversight than they do when working in their residency.


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## daedalus (Dec 20, 2009)

JPINFV said:


> Two major differences. First off, the vast majority of PA's charts are going to be signed off by a physician. Second, unless you're in the middle of BFE where (rarely, but it happens) the PA is working as coverage in a single coverage ER, the response time of an emergency physician if something goes bad is going to be measured in seconds, not minutes.



Actually, only around about 20% of charts done by most PA-Cs are signed off by physicians in most states. The number of charts needed to review are getting smaller, and in some states the only supervision requirement is meeting once a month with the supervising physician. I know of a PA who accomplishes this by a round a golf with is supervising physician. 

Of course, there are levels of competency. A new grad PA who lands a EM job will present most cases to his/her attending, where as a residency trained PA with a few years of additional work experience may only have to ask a few questions a month.


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## JPINFV (Dec 20, 2009)

DrParasite said:


> this discussion (as it always does) pretty much falls long certain lines: those who are medics think that EMTs can't do anything right, and every patient needs a medic JUST IN CASE they are suffering from an asymptomatic potentially ALS emergency, and EMTs who understand that most 911 calls aren't life threatening emergencies, and even those that are, they can be handled with BLS treatments until ALS arrives.


So you were to go to the hospital, you would be OK with the ER tech being the sole person in charge of your care, including assessment, treatment interventions, and disposition?


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## JPINFV (Dec 20, 2009)

daedalus said:


> Actually, only around about 20% of charts done by most PA-Cs are signed off by physicians in most states. The number of charts needed to review are getting smaller, and in some states the only supervision requirement is meeting once a month with the supervising physician. I know of a PA who accomplishes this by a round a golf with is supervising physician.
> 
> Of course, there are levels of competency. A new grad PA who lands a EM job will present most cases to his/her attending, where as a residency trained PA with a few years of additional work experience may only have to ask a few questions a month.



I stand corrected, how ever, 20% review and feedback is much more review than I've ever gotten on any of my EMS charts.


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## daedalus (Dec 20, 2009)

> however, your AAA abdominal pain, does he need ALS? well, if he hemodynamicly stable? so what is ALS going to do aside from take a ride to the hospital?
> 
> *With the EMT's very limited ability to take a history, preform a effective physical examination, and synthesize the information, how will an EMT know if a patient has a AAA? Does an EMT understand the predisposing factors for AAA, and the exam and history findings?
> *
> ...



10 characters. See above, *my responses in bold. *


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## zmedic (Dec 20, 2009)

The argument that a medic can provide a better assessment than an EMT isn't the question. The question is "can we figure out using dispatch protocols which patients can be handled by EMTs, who can then call in ALS if needed." Sure it would be great to just have paramedics on every ambulance and fire truck. Better yet, why don't we have doctors instead? It cost more to train a medic, and a heck of a lot more to pay them. Look at the difference between yearly salary for medic and an EMT. 

What we really need is more research. There has been some evidence that trauma patients do better with BLS rather than ALS. Now it isn't conclusive but the evidence suggests medics tend to do more on scene (airways, IVs) rather than rapid transport. But we need to look at a lot of different scenarios. If the evidence comes out that with appropriate EMD there is no difference in survival or morbidity having some patients cared for by BLS v an all ALS system, then we'll move that way. 

With healthcare reform things are going to change. There are already places where the ambulance services or FDs are saying "we can't pay two medics each $45K a year to run a double medic ALS truck, we need to figure out something else that works."


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## piranah (Dec 20, 2009)

RI explanation to the question above is the EMT-Cardiac....a porely trained protocol junkie...that has a 6 month education and can give 90% of medic drugs....trust me..look at RI and see you dont want that..I just recently became a medic from Basic and i have to say..during my training...I had no idea as a Basic..truly...Basics have a vital role but when it comes down to it a paramedic has the training,critical thought process, and the clinical experience(the actual "clinicals") that a Basic just does not have....the reason I became a medic was because i wanted to be the best in EMS, go to the top and bust my ***..be the "best i could be"..(i know im sorry).....and that entailed me getting my medic license....and that "simple temp" has a lot more going on than you think....


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## Sasha (Dec 20, 2009)

> your old guy with a fever does not need ALS. if the guy has had a fever for the past 3 days, waiting another hour for an IV to reverse his dehydration won't kill him.


Hello sepsis! So nice to meet you!

Obviously you've never responded to a nursing home to find a patient who'se had a fever "for three days" ready to code on you! Sepsis has an abysmal survival rate, the earlier you can start treatment, the better. How do you know from dispatch it's JUST a fever and they're not septic? Do you know how to assess someone for sepsis? Sepsis is a serious life threatning emergency that DOES require ALS. 



> your simple arm fracture doesn't need pain meds prehospitally. he won't die during the 30 minute transport time to the hospital (some would argue he doesn't even need an ambulance, just take him in the car to the ED).



No patient should be needlessly left in pain just because you have an inflated sense of self importance and think "you can handle it". Pain in itself can have adverse effects on the body and raise their anxiety level worsening their problem.



> and for many of your dispatched BLS emergencies, all they need is a ride to the hospital (or to their doctors office), not anything do be done to the other them before they get there.



You think that, at the BLS level, with your BLS assesments, without knowing the ALS scope and capabilities and how to do an ALS assesment. You want to be able to handle medical problems? Go to paramedic school.

I can't imagine how anyone would be satisfied with years and years as an EMT. Even at the paramedic level, I get frustrated with how little I can do to help the patient and how little I actually know. I couldn't imagine dealing with the patients I deal with at the basic level ever again.


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## MrBrown (Dec 20, 2009)

The whole "BLS vs ALS" argument is really an American thing, why, because America in its infinate wisdom is the only first world nation on earth that I know of which still subscribes to the long outdated, purist "basic life support" notion of the 1970s!

If we compare "BLS: American style" to the rest of the world, it's probably left in about 1990.  

If you think a "BLS" response is appropriate because 'all the patient needs is   ride to the hospital" than you are sadly mistaken.  Sub acute patients are much more intellectually demanding to diagnose, require a much higher level of knowledge and skill and are 100x more challenging than something like a cardiac arrest.

Now let's be honest with ourselves, you can write down what you need to do for a cardiac arrest on one side of A4; ask the Resuscitation Council and American Heart Assocation, they've done it.  You try writing down on one side of A4 what you need to do for a patient who presents with "my tummy hurts" - can't be done.

I am not talking "skills" here, sure this really could turn into a pissing match where we hold up all the other systems in the world and look at thier long lists of skills and Degree and Masters and Post Graduate qualifications then hold up the American system of an oxygen tank and a toaster.

But that's a symptom of the disease.  

Far be it from me to say what you guys need because I am not up on the intracacies of your totally discombobulated system but here's a few notions that would fix up this "BLS vs ALS" argument once and for-all

- Proper, federal level oversight; so long NHTSA!
- Proper funding
- One, national professional body
- At most, a handful of national industrial bodies, like the IAFF


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## CAOX3 (Dec 20, 2009)

Interesting discussion, how many times can we discuss the same topic?

Everybody for the most part in the US is under educated including the triage nurse with an associates degree.

If you haven't sat in a traditional university such as in Canada for four years then you have no business even arguing the point.

Only in America would a person with 6 months of training argue with someone with 9 months about who is more prepared to handle a life threatening emergency.


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## piranah (Dec 20, 2009)

excuse me but i spent the last 2 1/2 yrs....to get my medic and it was more credit hrs a week than a full time student at university...ooo and the whole idea of being under educated. Well, no comment. It is all what you put into it because i know at university all the first 2 yrs is learning how to drink lol......


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## BLSBoy (Dec 20, 2009)

It's not just the time spent in the traditional facility spent learning. 

Learning from the school of hard knocks is a helluva teacher. 
Learning from the crusty ol medics who are make a  helluva teacher. 
Not just being a rock, showing up, and going home. 

More to it then just formal education, but that DOES make up a large part of it.


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## Lifeguards For Life (Dec 20, 2009)

DrParasite said:


> your old guy with a fever does not need ALS.  if the guy has had a fever for the past 3 days,  waiting another hour for an IV to reverse his dehydration won't kill him.



Hey Doc, where do fevers come from?
(and only dr parasite...)


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## JPINFV (Dec 20, 2009)

Lifeguards For Life said:


> Hey Doc, where do fevers come from?
> (and only dr parasite...)



Mother nature when not delivering her XX monthly special!


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## Lifeguards For Life (Dec 20, 2009)

DrParasite said:


> your simple arm fracture doesn't need pain meds prehospitally.  he won't die during the 30 minute transport time to the hospital (some would argue he doesn't even need an ambulance, just take him in the car to the ED).  and for many of your dispatched BLS emergencies, all they need is a ride to the hospital (or to their doctors office), not anything do be done to the other them before they get there.



Speaking from a medical standpoint (not a humanitarian standpoint) you're views expressed here tonight, have been some of the more ignorant opinions I have read on this forum.

Researchers have provided information that can improve the ways in which pain is assessed and treated. At the same time, they have described the previously unknown and negative long-term effects of pain. As a result, pain issues are taken much more seriously today than in the past. Acute pain causes a release of "fight or flight" stress hormones. These stress hormones cause a breakdown of body tissues, as well as an increase in heart rate and blood pressure. The end result is a strain on the immune system which can complicate the effects of injury and slow down recovery. 

There has been an enduring belief that pain does not have long-term consequences. It is also falsely believed that babies and young children cannot remember painful events. These beliefs have resulted in the notion that pain in a young child is not important in their immediate or future development. However, researchers are accumulating information that indicates that these claims are false.

Some research now suggests that there are long-term consequences of pain in infants. This is especially the case for babies who spend a long time in hospital early in life and undergo many painful procedures without the benefit of any pain relief medication. However, researchers are also showing that the young child’s brain is very adaptable, or "plastic", in the way it deals with painful events. As a consequence, the brain is often able to find ways to compensate for these early pain events. Other research shows that babies who suffer a lot of pain from procedures early on without effective pain relief may go on to develop further pain as they grow older. They may also respond differently to pain during future pain events. 

Acute pain in adults left untreated, can potentially turn chronic. 

Now speaking from a humanitarian's view point, why would you want to deny a patient, who is in obvious pain, pain management? If you felt you were having any form of an emergency, and were in a substantial amount of pain, you would want measures taken to relieve your pain would you not?


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## Foxbat (Dec 20, 2009)

Lifeguards For Life said:


> At the same time, they have described the previously unknown and negative long-term effects of pain. As a result, pain issues are taken much more seriously today than in the past.


It is interesting that in Soviet/Russian medical literature it is widely recognized that pain is a major contributing factor of shock and one of the most important things in preventing and treating shock after trauma is pain management. In American literature I couldn't find much info about this. Can anybody explain what are the effects of pain on development of shock in case of major trauma?


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## rescue99 (Dec 20, 2009)

Lifeguards For Life said:


> The "ALS/BLS" (where else in medicine is there ALS and BLS? Is there such a thing as a BLS physician?) divide is simple. Is this patient going to see a physician in an emergency room? Then the patient deserves at least an assessment by a paramedic due to the extreme difference in education, training, diagnostic tools and interventions between basics and paramedics.
> 
> Hip fracture patients and adults with high fevers can not be accomodated properly at the Basic level. The hip fracture patient may be best suited with meds for pain managment, the adult with a high fever may benefit from intravenous fluids and/ or medications.



Ahhh...spoken like a true rookie ALS is not needed most of the time but, it is handy to have when more intervention is necessary. IFT definately benefits from a higher skill level too. 

I prefer teaching MFR, Basic EMT's and Specs hoping as they become Medics, they will not forget their roots. A great beginning generally makes a good Medic.


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## ffemt8978 (Dec 20, 2009)

It's been a while since I've had to to post this...


Play nice


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## JPINFV (Dec 21, 2009)

rescue99 said:


> Ahhh...spoken like a true rookie ALS is not needed most of the time but, it is handy to have when more intervention is necessary.



[I know... I used this line earlier, but no one likes answering this]

Would you accept going to the emergency room and having an ER tech examine, treat, and discharge you regardless of what your complaint was?


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## rescue99 (Dec 21, 2009)

JPINFV said:


> [I know... I used this line earlier, but no one likes answering this]
> 
> Would you accept going to the emergency room and having an ER tech examine, treat, and discharge you regardless of what your complaint was?



Well, we often receive treatment from a practitioner other than a pahysician so I'd have to say the situation can dictate the course.


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## medichopeful (Dec 21, 2009)

JPINFV said:


> [I know... I used this line earlier, but no one likes answering this]
> 
> Would you accept going to the emergency room and having an ER tech examine, treat, and discharge you regardless of what your complaint was?



Hell no!  

We go to the E.D. to get highly advanced, highly educated care as soon as possible, which an ER Tech cannot give.  

But EMS should be different, because for many patients their emergencies can wait for more advanced care. h34r:


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## VentMedic (Dec 21, 2009)

Foxbat said:


> It is interesting that in Soviet/Russian medical literature it is widely recognized that pain is a major contributing factor of shock and one of the most important things in preventing and treating shock after trauma is pain management. In American literature I couldn't find much info about this. Can anybody explain what are the effects of pain on development of shock in case of major trauma?


 
Many, many, many articles and I didn't even have to use my medical search engines. JCAHO now also has several measurements in place to see how a hospital is dealing with the pain of a patient.

Just type in Pain Trauma Mortality or Morbidity.

http://www.google.com/search?hl=en&source=hp&q=trauma+pain+management+morbidity&aq=f&oq=&aqi=


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## Sasha (Dec 21, 2009)

medichopeful said:


> Hell no!
> 
> We go to the E.D. to get highly advanced, highly educated care as soon as possible, which an ER Tech cannot give.
> 
> But EMS should be different, because for many patients their emergencies can wait for more advanced care. h34r:



Why should they have to wait? Would you want to wait 30 minutes for pain management?


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## Aidey (Dec 21, 2009)

rescue99 said:


> Well, we often receive treatment from a practitioner other than a pahysician so I'd have to say the situation can dictate the course.



That is after you have been triaged though, and your complaint has been assessed. Hospitals (and some clinics) have triage protocol that dictates who sees who and how fast and you can easily be transferred to to a MD (in a lot EDs) if they determine you need more advanced care. 

Granted in some smaller and more rural places the highest level of care at the medical facility may be a PA, or NP, especially at off times. They always have ways to transfer you to high care if they determine you need it though. 

Assuming all pts are ok with BLS is coming at it backwards in my opinion. The pt usually hasn't been assessed by anyone with any medical knowledge.  Dispatch kind of acts as a triage, but it doesn't replace it since we all know how accurate dispatches can be. 




medichopeful said:


> Hell no!
> 
> We go to the E.D. to get highly advanced, highly educated care as soon as possible, which an ER Tech cannot give.
> 
> But EMS should be different, because for many patients their emergencies can wait for more advanced care. h34r:



How do you know until the pt has actually been assessed? Yes, there are patients that would be ok without ALS care, but that should only be determined after the pt has been assessed. At least in a hospital the pt sees a triage nurse who determines if they can wait or not.


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## medichopeful (Dec 21, 2009)

Sasha said:


> Why should they have to wait? Would you want to wait 30 minutes for pain management?



I don't think it came across this way, but I was trying to be sarcastic.  If you go back and read my earlier post(s) in this thread, you'll see that we agree on this subject and that we're on the same page


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## medichopeful (Dec 21, 2009)

Aidey said:


> How do you know until the pt has actually been assessed? Yes, there are patients that would be ok without ALS care, but that should only be determined after the pt has been assessed. At least in a hospital the pt sees a triage nurse who determines if they can wait or not.



Like I said to Sasha, you and me are on the same page.  I was trying to be sarcastic, but it didn't translate well.


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## Sasha (Dec 21, 2009)

medichopeful said:


> I don't think it came across this way, but I was trying to be sarcastic.  If you go back and read my earlier post(s) in this thread, you'll see that we agree on this subject and that we're on the same page



Sorry I'm sick and loopy from cold meds :[


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## medichopeful (Dec 21, 2009)

Sasha said:


> Sorry I'm sick and loopy from cold meds :[



Not your fault.  I wasn't very clear.

I hope you feel better soon :sad:


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## eynonqrs (Dec 21, 2009)

I have some more to add here.

1) There are EMT's that are good out there. The problem is that there is less and less of them becuase of poor teaching. I had to prove my skills and do extensive ride along time as a volunteer and on a paid service before I was let go on my own in the back of the rig. They just don't do that anymore.

2) We do still need quailty EMT's. Rural areas or areas that can not afford paramedic services that rely on paid BLS or volunteers need good EMT's to provide care. There is one county above mine that the only ALS service that covers the entire county is hospital based chase unit with 2 medics. All BLS services are volunteer and serve rural areas where transport times can be in excess of 30 min to a hospital or 30+ min before ALS can get there. 

3) It would be nice if all towns could afford paid services, but in the state of the economy towns and counties are cutting public services so that leaves it up to volunteers and private services to provide care for the public.

4) It is a slap in the face to say that EMT's are not fit for IFT's. IFT's are good way to do pt assessments. 

5) There is also a way to help in pain managment on a BLS level, it is called making the pt comfortable. I can't tell you how many times I have used an air splint for ankle and wrist fx's. You are stabalizing the fx and you making a shock absorber. Also there is called taking and calming down the pt. 

6) I have been blessed to work with paramedics that were in the field for 20+ years. I had learned alot from them, because they took the time to help us out. If paramedics would stop thinking EMT's are so stuipd and nuture them you can help everyone out in the end.


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## So. IL Medic (Dec 21, 2009)

VentMedic said:


> All nursing students (in many states) can become CNAs. I have not seen any change in the legislation in the states where that is mandatory to become an RN.


 

In this part of the state, all the nursing programs now require completion of and work experience as a CNA. It's not a government thing but a school specific policy...probably why it was sucessfully implemented.




> Is that why they are called "assistants"? Aren't CNAs "assistants" also? Is that like a BLS RN?



Let's see...when I drop off a pt for a direct admit, CNAs take the vitals, transfer the O2, etc. while the RN heads straight for my pump and the med drip....sounds like a Basic to me!


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## JPINFV (Dec 21, 2009)

eynonqrs said:


> 4) It is a slap in the face to say that EMT's are not fit for IFT's. IFT's are good way to do pt assessments.



Good for the EMT-B isn't necessarily good for the patient. Saying that EMT-Bs aren't fit for IFTs isn't any more of a slap in the face as saying a painter isn't fit to make sculptures. The simple fact is that there isn't much in the way of training or education on the chronic conditions that make up the bread and butter work of IFT transports while a lot of the interventions taught to EMT-Bs are essentially useless. Imagine how much less complaining about dialysis transports if, for example, the childbirth module was moved from teaching about labor and assisting with birth (you aren't going to be helping a 70 y/o female deliver a baby) and instead focused on renal anatomy, physiology, and pathophysiology? Take extrication training (KED, etc) and move it to issues and pitfalls of transporting patients following hip replacement?

It isn't that EMT-Bs are too stupid for IFTs. It's that the emphasis in EMT-B course doesn't match up with the demands of IFT work. 



> 5) There is also a way to help in pain managment on a BLS level, it is called making the pt comfortable. I can't tell you how many times I have used an air splint for ankle and wrist fx's. You are stabalizing the fx and you making a shock absorber. Also there is called taking and calming down the pt.


...and what about the numerous patients who aren't going to see a large enough (like down to 1 or 2 out of 10) reduction in pain based on splinting and ice?


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## Aidey (Dec 21, 2009)

eynonqrs said:


> I have some more to add here.
> 
> 4) It is a slap in the face to say that EMT's are not fit for IFT's. IFT's are good way to do pt assessments.
> 
> ...




4. EMTs are not fit for all IFTs. Just because it is an IFT most certainly does not mean that it's perfectly fine for an EMT to take that patient. Yes, my EMT partner does take most of the IFTs, but that is only after we have both received report and we are both comfortable with him taking the patient. We've shown up at IFTs before that were dispatched as BLS transfers and the patients condition when we arrive is nothing close to what was dispatched. 

I've run into transferring facilities that don't understand the difference between BLS and ALS, and it isn't listed the CMS PCS, so they don't realize the pt with the IV actually needs ALS and not BLS (per my state). Sometimes the person calling for the transfer is not the person with the pt, and they only have limited info and don't know how bad the patient is. The patients condition can also change between the call and when we get there. 

Sometimes I even end up taking BLS patients, not because I don't want my partner taking the patient, but because it is what is best for the patient. For example if the RN tells us the patient does better with females, or in one case I spoke the patients primary language and my partner didn't 

5. Those are all things Paramedic's can, and should be doing too. Do you really feel like that is the most care a patient in pain needs during transport? 

6. I would hazard a guess that the majority of us do not think all EMTs are stupid. Undereducated, yes and so are Paramedics. But undereducated doesn't equal stupid.


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## MrBrown (Dec 21, 2009)

You guys are driving me totally bonkers!!!!!!!!!

*A PATIENT IS NOT A "BLS" PATIENT OR AN "ALS" PATIENT, THEY ARE ALL  PATIENTS*

.... and as such deserve an acceptable standard of care, skill and knowledge.  A tech-cert-gone-horribly-wrong couple hundred hour cookbook wonder with a Plano box full of drugs is *not* an acceptable level of care, knowledge and skill, for that matter *neither* is an oxygen tank and a toaster from a 120 hour course!.

Would you argue an ED nurse does not need the same level of education as they currenty have (2 or 4 year degree) as they are unable to do "skills" that a Paramedic can, they just have to ask the doctor so all we need to teach them is how to physically perform the skill and a quick introduction on why?

Until you stop categorising your patients as "advanced" or "basic" then you will still find need for a 120 hour toaster wonder.

We still have a "tiered" level of response here; differnece is our system is very progressive and has good scopes of practice; at our "basic" level we have 8 medications (including 3 analgesics).

Let's say I'm at my friends place and I get hit by a car; I can choose either a basic EMT with two semesters of college A&P and one each of pharmacology, patho, English, research and ethics *or* a Tech school wonder Paramedic with his Plano full of drugs.

I will choose the Paramedic any day of the week and twice today because he has really good drugs like fentanyl and morphine to control my pain!

I am not trying to turn this into a skills pissing match because we could quickly increase the EMT scope of practice and no real education would be required.


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## VentMedic (Dec 21, 2009)

So. IL Medic said:


> In this part of the state, all the nursing programs now require completion of and work experience as a CNA. It's not a government thing but a school specific policy...probably why it was sucessfully implemented.


 
Can you PM me the schools? Our nursing educators would love to know what is happening in other colleges. 

Some schools do like the nursing student to take the CNA test after their first semester but they are already accepted into the program and actually working as one is not required. 




So. IL Medic said:


> Let's see...when I drop off a pt for a direct admit, CNAs take the vitals, transfer the O2, etc. while the RN heads straight for my pump and the med drip....sounds like a Basic to me!


 
All medical professionals with licenses get the "basics". That should NOT be confused with BLS and ALS. The "basics" will be applied by all professionals on critically ill patients. An "assistant" assists a professional with their level of training regardless of how ill or not the patient is. If the CNA is there to "assist" the RN, that RN will not say this is a "BLS" or "ALS" patient so there is no "Basic". *It is medicine* and providing patient care without trying to label a patient according to provider.


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## rescue99 (Dec 21, 2009)

Medics manning triage has been a common practice for the last 12 or so years nearly everywhere here. All triage is ALS no matter which license is sitting there! If we'd bill for the level of care needed, not for the highest level on scene, I'd be a much happier tax payer ^_^

 Can't wait until the day Medics replace most RN's in the ER. It's been talked about for many years and of course, techs have already replaced a protion of them. Won't that stir up some burned beans from the bottom of the pot?


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## VentMedic (Dec 21, 2009)

rescue99 said:


> If we'd bill for the level of care needed, not for the highest level on scene, I'd be a much happier tax payer ^_^


 
So your community should not be entitled to ALS EMS?

Also, for individual billing, have you not heard about how ambulance services are charged? BLS, ALS1, ALS2, SCT? 

Understand how EMS, billing, reimbursement and your tax laws work. Don't take away ALS EMS from your community because you just want EMTs or feel you pay too much in taxes. Also look at your itemized tax bill and see all the charges there. You might be enlightened.



rescue99 said:


> Can't wait until the day Medics replace most RN's in the ER. It's been talked about for many years and of course, techs have already replaced a protion of them. Won't that stir up some burned beans from the bottom of the pot?


 
We've also talked about increasing the education of the paramedic for many years and that hasn't happened either.

In your hospital you mean they have increased patient to RN ratios to make budget? They have not "replaced" the RNs with techs in saying the techs are now equal to RNs. You really should understand the difference before flapping your fingers on a keyboard. Nor are Paramedics now RNs and given an RN license. I seriously doubt if their scope has expanded very much to even begin to do what an RN can do. However, the Paramedic might be okay in some limited roles in a little ED or a larger one that has a section for the simpler cases. But again, that is NOT to be confused with the ALS vs BLS crap that EMS uses. 

At least one thing California and NJ have done right is enforcing a decent nurse/patient ratio. 

The LVN who has much more education and APPROPRIATE training than the 700 hour medic mill Paramedic was told to advance or get out. It would seriously be a shame for any hospital to reduce their standard of patient care to just "techs". As well, when the Paramedic is working in the ED, it puts more stress on the RN who now has to supervise them and be held accountable for any screwups. When the Paramedic believes their 700 hours of training exceeds that of an ED RN who not only has at least 2 years of "basic" RN education but also specialty training for the ED, mistakes will be made. There is also nothing in the Paramedic curriculum that prepares them for the type of assessments that need to be done for long term (longer than 15 minutes) of care. 

What a sad, sad day if medicine resorts back to those with less than 1 year of education/training for the patients. That really is a very horrible statement about health care in the U.S. When this happens we might as well eliminate the Paramedic and just have all 110 hour EMTs on the ambulances. Too bad patients in the U.S. don't deserve anything more when it comes to health care.


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## Sasha (Dec 21, 2009)

> 4) It is a slap in the face to say that EMT's are not fit for IFT's. IFT's are good way to do pt assessments.



As an EMT I worked IFT for a year, and have been doing it as a medic for a couple months. I can comfortably say that the only thing an EMT should do at the IFT level is nursing home discharges, and even then I think a CNA or MA or LPN would be more suited for the job. 



> 5) There is also a way to help in pain managment on a BLS level, it is called making the pt comfortable. I can't tell you how many times I have used an air splint for ankle and wrist fx's. You are stabalizing the fx and you making a shock absorber. Also there is called taking and calming down the pt.



Yes. I'm a big fan of trying ice packs for pain before jumping into pain meds. However, the difference is when that doesn't work I have the ability to give them pain meds, a BLS ambulance does not.  I don't care how good you are at talking, talking does not make the pain go away. And once again, the patient should not suffer because of an EMT's inflated sense of self importance.



> If paramedics would stop thinking EMT's are so stuipd and nuture them you can help everyone out in the end.



I agree not every EMT is stupid, but that doesn't mean that they are equipped to deal with emergencies. At the end of the day the EMT with a bachelor's degree in biology or that EMT in med school is still just an EMT and is limited by the their very small scope for what they can do for a patient.


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## zmedic (Dec 21, 2009)

The basic truth is that IFT pays the bills and is how most private companies stay afloat. So financially it makes a lot more sense to have EMTs running transfters between 911 calls. 

Also I can't believe that people think most IFTs need a medic. When I was on the truck most of the IFTs we were doing were "80 yo man who is normally in a wheel chair needs to get to his doctor's appointment and back." Most of these patients medically stable, but for some reason they don't have the mobility to physically walk out and get in a cab. 

Sure there are the sicker people who are on lines, pressors etc. But most an EMT can handle. And if the stable patient who is going to the doctor suddenly codes, I'd much rather have an EMT in the back than an LPN whose code experience is "go call the doctor."


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## Scottpre (Dec 21, 2009)

zmedic said:


> I think fractures should be ALS. It's not about the ER not wanting to start IVs. It's about the fact that giving pain meds in the field for fractures is really one of the few cases where EMS can make people feel a lot better on the way to the hospital.



I worked a scene Dec 5 at the UW vs California game at Husky Stadium (Seattle, WA) where a guy had clearly dislocated his shoulder, but maybe had fractured his collar bone, too. I decide he needs better evaluation in the privacy/comfort of a first-aid room, so we wheel-chair him up to one. I also ask paramedics to evaluate him. 

One paramedic checks his right side CMS, confirms it's present (which our BLS team had already done) and then looks at me like "Why does this guy need us?". I had tried to explain my reasoning:

1- PT needed more thorough exam.
2- Given level of pain and guarding, likley more than just a simple dislocation of the R shoulder.
3- Transport would likely be needed.

Fortunately, the paramedic's partner thought a little more examintation was in order and sure enough, the PT looks like he may have fratured his R clavicle as well. No pain meds were offered. PT gets transported BLS (AMR) to the ED (ANY transport call, BLS or ALS, must goe through paramedics at Husky stadium, EMT B-'s can't order transport directly). 

Sometimes I feel like ALS doesn't want to bothered with the "routine stuff" untill it's late in the call, when the PT could have been given pain meds much earlier.


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## Sasha (Dec 21, 2009)

> And if the stable patient who is going to the doctor suddenly codes, I'd much rather have an EMT in the back than an LPN whose code experience is "go call the doctor."



i'd much rather have a paramedic. 

However, if I were bedconfined and being moved from bed to stretcher I'd much rather have a CNA or MA, who'se education greatly revolves around moving and positioning patients than an EMT who'se ticked off he's not on an emergency call.


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## VentMedic (Dec 21, 2009)

zmedic said:


> The basic truth is that IFT pays the bills and is how most private companies stay afloat. So financially it makes a lot more sense to have EMTs running transfters between 911 calls.
> 
> Also I can't believe that people think most IFTs need a medic. When I was on the truck most of the IFTs we were doing were "80 yo man who is normally in a wheel chair needs to get to his doctor's appointment and back." Most of these patients medically stable, but for some reason they don't have the mobility to physically walk out and get in a cab.
> 
> Sure there are the sicker people who are on lines, pressors etc. But most an EMT can handle. And if the stable patient who is going to the doctor suddenly codes, I'd much rather have an EMT in the back than an LPN whose code experience is "go call the doctor."


 
How much "medicine" is the EMT taught? Basic first aid is not adequate since many of these patients require little to no first aid. A CNA is also better trained to move some of the medical needs patients. They are familiar with some of the disease processes and the special care they may require. If the EMTs at least has some of the training that a CNA gets, then they might be better qualified to even take some of these patients to and from the doctors' offices. CNAs also have CPR cards and most of our hospital CNAs have done CPR many, many more times than some of the EMTs working 911 calls. The training of the EMT is just not adequate or appropriate for medical patients. 

I'm also glad you mentioned the LPN. LPNs have more education and "hours of training" than most U.S. Paramedics. For a long time they did work codes in the EDs, ICUs and L&Ds when it took awhile for doctors to arrive and they still continued to work the code. Nobody just leaves the patient when a doctor arrives.   But, healthcare has progressed and the 1 year LPN is no longer found in these areas. Yet, we still allow 3 month wonder Paramedics on the streets. What's with that? What does EMS continue to stand behind low standards when every other profession is raising theirs.


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## VentMedic (Dec 21, 2009)

Sasha said:


> i'd much rather have a paramedic.
> 
> However, if I were bedconfined and being moved from bed to stretcher I'd much rather have a CNA or MA, who'se education greatly revolves around moving and positioning patients than an *EMT who'se ticked off he's not on an emergency call*.


 
And of course there is that issue.

So many EMTs get their patch thinking they will be just like what they have seen on TV. The schools didn't tell them about IFT transport and there was not much of "that" medical stuff mentioned.

Some here should sit in the reception area or a nurses' station at a hospital to hear some of the hideous comments about "BS" calls and "BS" patients spoken openly. It definitely doesn't do much to build up respect for the EMT(P). There have even been comments in threads on this forum about lizard transfer trucks. It just shows a lack of knowledge pertaining to medicine and patient care.


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## zmedic (Dec 21, 2009)

Sasha; said:
			
		

> i'd much rather have a paramedic.
> 
> However, if I were bedconfined and being moved from bed to stretcher I'd much rather have a CNA or MA, who'se education greatly revolves around moving and positioning patients than an EMT who'se ticked off he's not on an emergency call.



IFTs don't pay enough to fund having a medic do all the transfers, nor will insurance reimburse for ALS transfer if it's a BLS patient.  

Again, if you had CNAs or LPNs doing transfers then that unit can't be used for 911 calls. I think EMTs can handle many basic transfers such as to doctors offices, and it helps the system and makes money while waiting for 911 calls to drop. 

I'm not sure how much you need to know about disease processes to take the patient to the doctor. It's more of:

1. How do I get this patient from bed to stretcher/wheel chair, stretcher to rig, rig to office and reverse?

2. Does this patient look sicker than I can handle? 

For basic IFTs you aren't giving meds, you aren't managing fluids, if doesn't really matter who knows more about the patients underlying disease. It's simply a transport. 

Again this is why I really like mixed EMT/medic trucks. Because you have have the EMT in back getting experience on basic transfers, but if you show up and the patient looks unstable or gets worse in route the medic can attend. And it is more cost efficient than having double medic trucks run transfers. 

Then again, if you want to make your paramedics want to quit, there is nothing like making them attend on lots of basic IFTs.


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## EMSLaw (Dec 21, 2009)

Wow.  This is quite the thread.  Good basic first aid skills are important for any level of provider.  I've had patients, both on the ambulance and otherwise, who needed proper splinting and bandaging, and it's unfortunate how little of that is taught, even at the EMT level - honestly, even if EMT class is supposed to teach first aid, they do a very poor job of it.  I learned more of the "basics" in a first responder class than I learned in EMT-B school.  

The advantage of paramedics is that they have more tools in the box for when things go wrong.  Anecdotally, it's unfortunate that they use so few of them, which in my view hurts some of the arguments made here.  At least where I live, if the only reason a paramedic is called is for pain relief, then you'll be dissapointed - a patient with a fracture or dislocation (or any other condition) may be in great pain but the paramedics (either because of their inclination, or that of their medical director and protocols) will not give analgesics.  I can't tell you how often I've transported a patient where every bump was agony.    

Even if EMT's are going to be first responders, they should be adequately trained to that function, which requires more than the current level of training - whether it be by college level courses or a longer technical certificate.  Our profession as a whole needs to be more concerned about alleviating the pain and suffering of our patients, and less about protecting our own egos and "turf."  

No matter how long the classes are, those of us who want to do it will do it (speaking for myself, as long as there is an option aside from full-time days, but that's neither here nor there).  Those who don't want to be bothered... won't be.  Maybe we'll have less prehospital providers, but after a year or so on the street, I don't see that as a bad thing.


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## VentMedic (Dec 21, 2009)

zmedic said:


> IFTs don't pay enough to fund having a medic do all the transfers, nor will insurance reimburse for ALS transfer if it's a BLS patient.


 
But insurance companies are willing to pay for RN or other professionals instead of Paramedics.

Maybe if they were actually informed to what they are paying for an not rec'g they might have a different opinion. The crime is the insurance companies may be paying for a transport that has a stretcher as a very expensive "taxi" but the providers really can't provide much more care than those who are "drivers" with a CPR card on a medi-van. 

The EMT does not need to disapper but rather just be "educated" rather than just trained. 




zmedic said:


> Again, if you had CNAs or LPNs doing transfers then that unit can't be used for 911 calls. I think EMTs can handle many basic transfers such as to doctors offices, and it helps the system and makes money while waiting for 911 calls to drop.


 
How many EMTs actually do get to 911 calls?




zmedic said:


> I'm not sure how much you need to know about disease processes to take the patient to the doctor. It's more of:
> 
> 1. How do I get this patient from bed to stretcher/wheel chair, stretcher to rig, rig to office and reverse?
> 
> ...


 
The thing is many EMTs don't most don't know how sick their patients are. Read some of the previous threads and see how little knowledge some have about what a fever can do to an elderly patient. But then, taking a temperature or even asking for one is something rarely done by EMTs.



> Then again, if you want to make your paramedics want to quit, there is nothing like making them attend on lots of basic IFTs.


 
Another example that some just go into EMS for the cool trauma calls but really don't want to do much patient care. I personally enjoy having calls where the patients are not always on death's door or need intense medical treatment. Sometimes it is good to just do a thorough assessment and have a chance to converse with a patient. Yet, too few in this profession want any part of that boring crap which is associated with good bedside care on an ambulance. 

I also would rather have a Paramedic or RN as a partner. For specialty transport, I would rather have a professional driver from the transport pool rather than an EMT who has a limited knowledge of medicine in reality but vast in their own belief might influence the way they drive putting the team and patient at risk.

However, again I will emphasize, the EMT does not need to disapper but rather just be "educated" rather than just trained.


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## emtzach03 (Dec 21, 2009)

this will be short. in both aspects bls or als, you are only as good as the amount of time you have been doing it. I know of senior BLS crews that have better diagnostic ability then a brand new ALS crew. The only difference is is the paragod attitude that is presented to the BLS crew. ALS has many ways of diagnosing illness and at times find them selfs overthinking and forgeting the simple basics that They used to use. Medications especially for pain is not used for many reasons, however proper pt care, placement, and positioning is what is important. It ultamitely comes down to the person careing for the pt. It can not be taught it has to be learned. As far as tho oversatuteration of ALS that just comes down to the amount of lawsuites over the years and people sayin "well if there was an ALS crew closer the Pt may have not........." its all monday morning quarterbacking in my opinion


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## VentMedic (Dec 21, 2009)

emtzach03 said:


> this will be short. in both aspects bls or als, you are only as good as the amount of time you have been doing it.* I know of senior BLS crews that have better diagnostic ability then a brand new ALS crew. The only difference is is the paragod attitude that is presented to the BLS crew.* ALS has many ways of diagnosing illness and at times find them selfs overthinking and forgeting the simple basics that They used to use. Medications especially for pain is not used for many reasons, however proper pt care, placement, and positioning is what is important. It ultamitely comes down to the person careing for the pt. *It can not be taught it has to be learned.* As far as tho oversatuteration of ALS that just comes down to the amount of lawsuites over the years and people sayin "well if there was an ALS crew closer the Pt may have not........." its all monday morning quarterbacking in my opinion


 
Written like an EMT-B...

Do all the EMT-Bs here only aspire to be a 110 hour minimally trained provider? 

If it takes you "years" to master the few skills of EMT, maybe you shouldn't advance and will be destined to stay as an EMT. But, don't hold the rest of the profession back by continuing to agrue for the least amount of care provided to the patients by the least educated/trained provider.

Does anyone here even want to know what medicine is all about? Its really a very vast field.

Why do some take this "paragod" bashing attitude? Does a few hundred hours of education and training with a little extra responsibility really intimindate or frighten some of the EMTs here to where they get this attitude about Paramedics, nurses or doctors? 

If you really think you are just like a Paramedic, why don't you have what it takes to finish a few hundred hours of schoool to get the certificaton? Why don't you go ahead and walk the talk? 

Some things do come with experience but if you have no clue about various disease processes and certain aspects of treatment, it doesn't matter how good your intentions are. Street medicine can be done a lot better if one has some real education to apply to what is being taught in the street. 

I personally feel there are some EMTs on this forum who do want to have more knowledge and education than just the U.S. EMT has to offer and do want to provide more knowledgable care. But, why do some constantly want to argue that 110 hours of training is acceptable patient care?


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## firecoins (Dec 21, 2009)

VentMedic said:


> How much "medicine" is the EMT taught? Basic first aid is not adequate since many of these patients require little to no first aid. A CNA is also better trained to move some of the medical needs patients. They are familiar with some of the disease processes and the special care they may require. .



Based on my experience I would tend to doubt that. CNAs seem to know very little. They tend to get in the way, trying to clean patients up why preventing access to paramedics.


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## VentMedic (Dec 21, 2009)

firecoins said:


> Based on my experience I would tend to doubt that. CNAs seem to know very little. They tend to get in the way, trying to clean patients up why preventing access to paramedics.


 
How much do you know about CNAs? Have you ever looked at their education and training? 

I would say you haven't a clue. You have probably never worked along side them and have y entered some health care facilities with an attitude about being pulled away from sleep or the computer to do some BS call. 

Maybe what you actually saw was the CNAs protecting the patient's dignity and privacy even at a time of crisis. That is often something some EMTs forget. Example: bringing  an almost naked conscious and alert patient without even a sheet to cover them through a busy ED or hospital entrance. Or, transporting a routine patient by just wrapping them in the same sheets the patient may have just had a bowel movement on and screaming to the CNAs to get lost so the hospital deal with it. Yeah, I can easily see you doing that.


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## reaper (Dec 21, 2009)

Why is it that time and again you see the statement that medics forget the basics?

Do you think we walk up to a pt and not care if the are breathing?

If you need years to master the basics, then we are in worse shape then we could even imagine. It takes less then 10 seconds to determine ABC's. This is not something that is a great skill to master. Most medics have this out of the way in the first few seconds with the pt. Then they are moving on to determining what this pt needs and what treatment is needed. We do not have a "scoop and run mentality". We use the education that we have, to determine what is best for the pt.

I have heard EMT's complain that a medic sat on scene to long ,trying to get an IV or ETI. Have you ever stepped back to look and consider that maybe they determined that is what the pt needed at the time? Some say "we are only 10 minutes from a hospital, why delay"? Do you know what can happen to a Pt's brain function with 10 minutes of inadequate oxygenation or perfusion of the brain?

Yes, there are terrible medics out there. But, the majority are excellent providers and have the knowledge to do what needs to be done.

There are a lot of knowledgeable and educated EMT's out there. But, I look at someone who has been an EMT fulltime for 5 or more years as someone who is either to lazy or to scared to advance their education. If they cared for their Pt's care as much as they preached, they would be eager to advance their knowledge of medicine, to help their Pt's the best way possible.


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## emtzach03 (Dec 21, 2009)

VentMedic said:


> Written like an EMT-B...
> 
> Do all the EMT-Bs here only aspire to be a 110 hour minimally trained provider?
> 
> ...


its amazing i guess you are one of those paragods i was refering to. i have no intentions on arguaing here i was making a point that there are very good BLS crews out there i am one of them you could ask for my references, and excuse the :censored: out of me for chosing to go into the army. It is taught BLS BEFORE ALS. Yes training is minimal its up to the indvidual to excel in there personal training. Dont preach so much you just look like a donkey doing so


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## VentMedic (Dec 21, 2009)

emtzach03 said:


> its amazing i guess you are one of those paragods i was refering to. i have no intentions on arguaing here i was making a point that there are very good BLS crews out there i am one of them you could ask for my references, and excuse the *:censored: out of me for chosing to go into the army.* It is taught BLS BEFORE ALS. Yes training is minimal its up to the indvidual to excel in there personal training. Dont preach so much you just look like a donkey doing so


 
We are not arguing about you being in the Army.  Why must you mention that when talking about the U.S. EMT training?   We are not discussing what someone in the Army can do and please do NOT insult those in the Army who are well trained and educated to provide medical care.

What's with the BLS before ALS?  ALS crews can do the basics of care also.   Again, you need to understand "basics" of medical care and medicine and forget the "BLS/ALS" as labeling patient care.


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## EMSLaw (Dec 21, 2009)

VentMedic said:


> How much do you know about CNAs? Have you ever looked at their education and training?



I hate the comparison between EMTs and other allied health providers, as if the implication is that because certain other health workers have minimal education, we can as well.  That doesn't make a lot of sense, especially when you consider that while we may be twenty minutes from an ER, they are twenty seconds away.  EMTs and Paramedics have some of the greatest freedom to act in an emergency, and conversely the least didactic work to back it up.  While that may have been fine in the days of Johnny and Roy, it's not so much now. 

Incidentally, apparently the combination of an EMT-B and an LPN is the perfect storm of medical disaster.  Note the State says that the EMT was the highest trained /pre-hospital/ practitioner at the scene, and should have known what to do.  That should be a sobering reminder that we owe it to our patients to have a freaking clue.


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## Sasha (Dec 21, 2009)

firecoins said:


> Based on my experience I would tend to doubt that. CNAs seem to know very little. They tend to get in the way, trying to clean patients up why preventing access to paramedics.



Actually I'd be glad they're trying to clean the patient up before you take them. No telling how long they'd have to sit in their feces at the hospital before someone could get to them and change them, all the while their skin is breaking down and feces getting in ulcers.

I've learned if you jump in to help them, they'll be done quicker so you can do what you need to.


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## VentMedic (Dec 21, 2009)

EMSLaw said:


> Incidentally, apparently the combination of an EMT-B and an LPN is the perfect storm of medical disaster. Note the State says that the EMT was the highest trained /pre-hospital/ practitioner at the scene, and should have known what to do. That should be a sobering reminder that we owe it to our patients to have a freaking clue.


 
I like the way NJ posts all the information about each action taken.

http://www.state.nj.us/health/ems/legal.shtml#basics


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## emtzach03 (Dec 21, 2009)

VentMedic said:


> We are not arguing about you being in the Army.  Why must you mention that when talking about the U.S. EMT training?   We are not discussing what someone in the Army can do and please do NOT insult those in the Army who are well trained and educated to provide medical care.
> 
> What's with the BLS before ALS?  ALS crews can do the basics of care also.   Again, you need to understand "basics" of medical care and medicine and forget the "BLS/ALS" as labeling patient care.



i brought up my current work as reference to not having gotten my paramedic as of yet. my point of bls befor is that medics look down on basics as you have brought this to light. I understand you can perform bls care i was only upset at your comment attacking my level as a civilian, and you think i am insulting my brothers. i would give my life while rendering care... would you


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## VentMedic (Dec 21, 2009)

emtzach03 said:


> i brought up my current work as reference to not having gotten my paramedic as of yet. my point of bls befor is that medics look down on basics as you have brought this to light. I understand you can perform bls care i was only upset at your comment attacking my level as a civilian, and you think i am insulting my brothers. i would give my life while rendering care... would you


 
In my experience, I am of more use alive to those I serve in or out of the service.  In the civilian world, scene safety is taught. 

Again, DO NOT compare the U.S. EMT-B with the training of a medic in the Armed forces. 

Do you not understand the pecking order of any profession? Is there not a rank existence in the Army? Or, do you believe you are equal or better than your superior officers?


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## EMSLaw (Dec 21, 2009)

VentMedic said:


> I like the way NJ posts all the information about each action taken.
> 
> http://www.state.nj.us/health/ems/legal.shtml#basics



For the record, a quick check of the nursing license list on another state website shows that no action was taken against the LPN.


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## VentMedic (Dec 21, 2009)

EMSLaw said:


> For the record, a quick check of the nursing license list on another state website shows that no action was taken against the LPN.


 
The nurse was not on duty. The nurse was the same as a lay person in this situation and the EMT should have realized that. 

If I come upon a scene while off duty, I can only give care as a lay person would but with a little more knowledge. I will not be able to take control of that scene as a medical provider...unless in Florida where I could if still employed with the FD.

The legal outcome would not have been any different if a doctor has been present unless the doctor announced he/she was assuming care of the mother or baby and offered to accompany them in a lead provider role assuming the responsibilities under his MD license.


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## EMSLaw (Dec 21, 2009)

VentMedic said:


> The nurse was not on duty. The nurse was the same as a lay person in this situation and the EMT should have realized that.
> 
> If I come upon a scene while off duty, I can only give care as a lay person would but with a little more knowledge. I will not be able to take control of that scene.



The EMT wasn't really on duty either - he stopped and picked up an ambulance from the Rescue Squad, without a partner, and went to the scene, rather than calling 911.  That was part of the problem with the call.  A fully manned ambulance, and probably ALS backup, should have been present.  

From start to finish, the call was fouled up.


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## Chimpie (Dec 21, 2009)

*Keep the thread clean and on topic or it will be closed.*


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## JPINFV (Dec 21, 2009)

I would argue that once he decided to man an ambulance that he is de facto on duty.


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## VentMedic (Dec 21, 2009)

EMSLaw said:


> The EMT wasn't really on duty either - he stopped and picked up an ambulance from the Rescue Squad, without a partner, and went to the scene, rather than calling 911. That was part of the problem with the call. A fully manned ambulance, and probably ALS backup, should have been present.
> 
> From start to finish, the call was fouled up.


 
Yes, he bypassed the EMS system since he has access to an ambulance which he used as his own personal transport vehicle for his sister.

But. *he* assessed and determined the baby to be dead.

Can EMTs pronounce death in NJ? 

He also did not know the significance of the placenta delivery or failed to clamp the cord. 

In essence, he did not know what to do for the birth of a baby or the determination of death regardless of who else was with him. It appeared he was also doing most of the hands on.

He should also have known that some babies are born in hot tubs to be called a "natural water birth"...not that I compare a toilet bowl to a hot tub.


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## rhan101277 (Dec 21, 2009)

VentMedic said:


> Yes, he bypassed the EMS system since he has access to an ambulance which he used as his own personal transport vehicle for his sister.
> 
> But. *he* assessed and determined the baby to be dead.
> 
> ...



Yeah that toilet water will definitely be to cold for them.  I think they can stay under for a 30 seconds to a minute as long as you don't stimulate them or cut the cord while they are under the water.  I read through some of those revocations and some of the care rendered makes no since.  I don't see how some of them got through class.  I think any mother would get their baby out of the toilet, regardless of whether they thought it was dead or not especially since this baby was almost term.


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## EMSLaw (Dec 21, 2009)

VentMedic said:


> Yes, he bypassed the EMS system since he has access to an ambulance which he used as his own personal transport vehicle for his sister.
> 
> But. *he* assessed and determined the baby to be dead.
> 
> ...



As I said, fouled up from start to finish.

And no, EMT-Bs cannot pronounce in NJ, which is yet another reason recussitative efforts should have been started.  There was an amendment to the law introduced recently that would allow EMT pronouncements in certain limited cirumstances - basically the times you would not initiate CPR (obvious death, such as decapitation, lividity, rigor, decomposition).  But that's not the law yet, and I'm not sure it should be.

Also, I would argue that when the child was born, there were then two patients, and even at that point, given the critical state of the baby, a second ambulance should have been called.  

And finally, and no less important, I was taught in the cases of a potential miscarriage (which I don't think this was, but let's presume for a minute) if the fetus looks like a baby, it should be treated like a baby.  That is, wrapped up in a blanket and taken to the hospital, not put in a garbage bag.


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## VentMedic (Dec 21, 2009)

EMSLaw said:


> if the fetus looks like a baby, it should be treated like a baby. That is, wrapped up in a blanket and taken to the hospital, not put in a garbage bag.


 
That's at least commonsense out of respect for both the baby and the mother.


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## medichopeful (Dec 21, 2009)

EMSLaw said:


> From start to finish, the call was fouled up.



The main problem was the HUGE conflict of interest.  It was his sister after all.  He should have been intelligent enough to get OUTSIDE help.


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## Aidey (Dec 21, 2009)

zmedic said:


> Also I can't believe that people think most IFTs need a medic. When I was on the truck most of the IFTs we were doing were "80 yo man who is normally in a wheel chair needs to get to his doctor's appointment and back." Most of these patients medically stable, but for some reason they don't have the mobility to physically walk out and get in a cab.



I wouldn't say I think most IFTs need a medic, but that assuming none of them do isn't the way to go about it. In my system there is no dedicated transfer ambulance, we all run them, and we are an EMT/Paramedic crew.

The % of transfers that are called out as "BLS" and end up needing a medic is probably pretty low, but it does happen, and because of that I'm glad I was there. On the flip side, we have done transfers that don't meet the CMS ambulance transfer criteria, but because there is no wheel chair van available at night we do them. 

I also think there is a difference between a regularly scheduled transfer for your 80 yo male and an unscheduled one for a 75 yo F who is suddenly needing 4lpm to maintain her sats instead of 3lpm. The 80 yo man who is being transferred to his GP and back may end up being the sicker patient overall, but he may be stably sick and doesn't need intervention, if that makes sense.


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## MrBrown (Dec 21, 2009)

Come on folks, what is with the whole "BLS vs ALS patient" thing, wow, I mean it's just totally foreign to me.

If I was working with ALS and went to a patient who we examined and came up with "stubbed toe" for example, if we got on the radio and said "oh this patient doesn't need us, what is [the BLS vehicle] doing? Have them come transport as this is a BLS patient" I can guarentee you that I'd probably get fired.

Doesn't matter who turns up, if the ALS vehicle is the only one free and roll up to the job, the crew doesn't care how sick or hurt you are and if your condition is "compatible" with thier skillset or not.

Again I am hesitant to turn this into a pissing match about skills because skills are easy and require minimal education.

Understandably there are larger issues here than provider unwillingness like funding, tax and regulatory regimes.  But let's immagine that those are fixed for a moment please, so *why should the most developed nation on earth keep the least developed entry-to-practice standard?*.

I'd be interested to hear what you think.


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## CAOX3 (Dec 21, 2009)

EMSLaw said:


> As I said, fouled up from start to finish.
> 
> And no, EMT-Bs cannot pronounce in NJ, which is yet another reason recussitative efforts should have been started.  There was an amendment to the law introduced recently that would allow EMT pronouncements in certain limited cirumstances - basically the times you would not initiate CPR *(obvious death, such as decapitation, lividity, rigor, decomposition).  *But that's not the law yet, and I'm not sure it should be.
> 
> ...



So your EMTs initiate CPR on decapitated pts?  I hope not.


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## Lifeguards For Life (Dec 21, 2009)

CAOX3 said:


> So your EMTs initiate CPR on decapitated pts?  I hope not.



I think those were examples of conditions that warrant a death be pronounced on scene, hence CPR would not be warranted


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## CAOX3 (Dec 21, 2009)

EMSLaw said:


> As I said, fouled up from start to finish.
> 
> And no, EMT-Bs cannot pronounce in NJ, which is yet another reason recussitative efforts should have been started.  There was an amendment to the law introduced recently that would allow EMT pronouncements in certain limited cirumstances - basically the times you would not initiate CPR (obvious death, such as decapitation, lividity, rigor, decomposition).  *But that's not the law yet, and I'm not sure it should be.*
> Also, I would argue that when the child was born, there were then two patients, and even at that point, given the critical state of the baby, a second ambulance should have been called.
> ...



Thats not how I read it.


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## rescue99 (Dec 22, 2009)

medichopeful said:


> The main problem was the HUGE conflict of interest.  It was his sister after all.  He should have been intelligent enough to get OUTSIDE help.



The emotions often take over when loved ones are involved. Such a sad situation.


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## EMSLaw (Dec 22, 2009)

CAOX3 said:


> Thats not how I read it.



Well, you read it wrong.

EMT's cannot pronounce.  They can decide not to initiate resuscitation in cases of obvious death.  So, no, we do not start CPR on decapitated victims, or on skeletons, or on persons with rigor mortis or fixed lividity.  But that person is still not legally dead until a paramedic, RN, doctor, or other person authorized by statute arrives to pronounce.  

The proposed change to the law here would allow EMTs to pronounce in situations where there is obvious death.  To clarify what you had such a problem with - I'm not sure that EMTs should pronounce.  Why?  Honestly, because I'm pretty sure someone will screw up obvious death.


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## CAOX3 (Dec 22, 2009)

EMSLaw said:


> Well, you read it wrong.
> 
> EMT's cannot pronounce.  They can decide not to initiate resuscitation in cases of obvious death.  So, no, we do not start CPR on decapitated victims, or on skeletons, or on persons with rigor mortis or fixed lividity.  But that person is still not legally dead until a paramedic, RN, doctor, or other person authorized by statute arrives to pronounce..



Maybe not legally.  The fact they are allowed to withold CPR after assessment is a form of pronouncment.




EMSLaw said:


> The proposed change to the law here would allow EMTs to pronounce in situations where there is obvious death.  To clarify what you had such a problem with - I'm not sure that EMTs should pronounce.  Why?  Honestly, because I'm pretty sure someone will screw up obvious death.



Yes and paramedics never screw this up?  Shall I post some links?


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## EMSLaw (Dec 22, 2009)

CAOX3 said:


> Yes and paramedics never screw this up?  Shall I post some links?



I'm sure they do, but they have access to ECG and additional training.  And at least here, paramedics only pronounce after a four lead shows asystole and they call medical control to obtain approval.  

Are you just arguing for the sake of arguing, or do you support the idea of basics pronouncing?


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## MrBrown (Dec 22, 2009)

i've heard of dead people getting a GCS of 6 so yeah I'd say somebody gonna screw it up somewhere ......


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## 18G (Dec 22, 2009)

I understand how EMT-B's feel having worked and volunteered as one for a FD and 911 EMS for a lot of years. However, I must admit that I felt helpless and very limited as an EMT-B many times. These feelings were a main motivating factor for wanting to become a Paramedic. And while there are many great EMT's out there that know far more than required, without the authorization and tools to use that knowledge, it doesnt do the patient any good. 

I agree that Paramedics should be minimum staffing on all ambulances regardless of call type. If the crew consists of a Paramedic and an EMT, and the EMT can clearly handle than yes, allow the EMT to manage the call while providing oversight.

I don't have a big problem with using the terms BLS vs ALS to distinguish levels of care patients need. BLS and ALS are just descriptors. Perhaps it makes sense to just say "patient care", but I dont see what the big deal is.


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## rescue99 (Dec 22, 2009)

18G said:


> I understand how EMT-B's feel having worked and volunteered as one for a FD and 911 EMS for a lot of years. However, I must admit that I felt helpless and very limited as an EMT-B many times. These feelings were a main motivating factor for wanting to become a Paramedic. And while there are many great EMT's out there that know far more than required, without the authorization and tools to use that knowledge, it doesnt do the patient any good.
> 
> I agree that Paramedics should be minimum staffing on all ambulances regardless of call type. If the crew consists of a Paramedic and an EMT, and the EMT can clearly handle than yes, allow the EMT to manage the call while providing oversight.
> 
> I don't have a big problem with using the terms BLS vs ALS to distinguish levels of care patients need. BLS and ALS are just descriptors. Perhaps it makes sense to just say "patient care", but I dont see what the big deal is.




EMT/Medic rigs are common place. It is a good comprimise IMO. Provides what is needed and saves financial resources too. Now, if we could just get companies and FD to understand BLS assessment comes first, not as an after thought. Proper billing using mixed staffing and billing for only the service provided, lowers the overall cost of providing service while still providing both levels of care.


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## Lifeguards For Life (Dec 22, 2009)

MrBrown said:


> i've heard of dead people getting a GCS of 6 so yeah I'd say somebody gonna screw it up somewhere ......



I've heard deceased (and a living patient or two) recieve GCS of 0,1, or 2:unsure:


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## JPINFV (Dec 22, 2009)

Screwing up GCS is nothing. The clinical genectist that came in a taught a class told us a story of a PMD who screwed up reading a Huntington's Disease screen. Huntington's Disease is caused when a triplet repeat on chromosome 4 goes past 36 repeats. Now the screens come back with two numbers, one for each chromosome. The poor patient's PMD decided to add the numbers together (it was something like 17 and 23), and told her that she was going to develop Huntington's Disease eventually. Oh course she goes to see the clinical genetists, he takes one look at the test and tells her the good news.


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## Foxbat (Dec 22, 2009)

VentMedic said:


> Many, many, many articles and I didn't even have to use my medical search engines. JCAHO now also has several measurements in place to see how a hospital is dealing with the pain of a patient.
> 
> Just type in Pain Trauma Mortality or Morbidity.
> 
> http://www.google.com/search?hl=en&source=hp&q=trauma+pain+management+morbidity&aq=f&oq=&aqi=


Ah, I must have used wrong keywords. Thanks.
I'm still surprised that little attention is paid to it in EMT-B and ITLS classes, though.


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## CAOX3 (Dec 22, 2009)

EMSLaw said:


> I'm sure they do, but they have access to ECG and additional training.  And at least here, paramedics only pronounce after a four lead shows asystole and they call medical control to obtain approval.
> 
> Are you just arguing for the sake of arguing, or do you support the idea of basics pronouncing?



Yes Im arguing just to argue, thats productive.  

In my system our statues are written as yours, the only difference no medic, nurse or medical doctor has to confirm or pronounce, if obvious signs are present the EMT can pronounce.

We havent had a problem that Im aware of.


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## BLSBoy (Dec 24, 2009)

EMSLaw said:


> The advantage of paramedics is that they have more tools in the box for when things go wrong.  Anecdotally, it's unfortunate that they use so few of them, which in my view hurts some of the arguments made here.  At least where I live, if the only reason a paramedic is called is for pain relief, then you'll be dissapointed - a patient with a fracture or dislocation (or any other condition) may be in great pain but the paramedics (either because of their inclination, or that of their medical director and protocols) will not give analgesics.  I can't tell you how often I've transported a patient where every bump was agony.



I'm guessing you live in an area where the Medics all wear white shirts, are paid poorly, and mostly all have bad attitudes?

Being a Medic in Jersey in the far South, we have started reevaluating our pain protocols, and our docs are allowing much more to be administered, in both the number of pts and how much we give, as long as it is clinically necessary.


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## Akulahawk (Dec 24, 2009)

Out here, Santa Clara County used to have a "Field Pronouncement" protocol... A few years ago, they changed the terminology to something like "Field Determination of Death".

What makes thing interesting is that if I was working in that county, I could determine someone dead after following a given protocol... but a Deputy over there could do the pronouncement... Go figure.


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## EMSLaw (Dec 24, 2009)

BLSBoy said:


> I'm guessing you live in an area where the Medics all wear white shirts, are paid poorly, and mostly all have bad attitudes?
> 
> Being a Medic in Jersey in the far South, we have started reevaluating our pain protocols, and our docs are allowing much more to be administered, in both the number of pts and how much we give, as long as it is clinically necessary.



Got it in one.  I'm glad to hear that there are advances being made.  Be nice if certain other projects got onboard.


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