The practicality of EMT Basics as an emergecy responder

[Tigger]

Well depends on what you mean by care, the faster you get them to a hospital, the faster they get definitive care. If you are substantially delaying their transport because you insist on having Paramedics take them, are you giving them better faster care?



So why is this volly department only responding to 10% of the calls? Is this all they are dispatched to, or all they respond to when dispatched? Either way something doesnt make sense. As for beating them to the scene, I can say that I personally have never seen that happen where Im at. Usually its a substantial wait before ALS gets there.

Imagine its winter and someone crashes their snowmobile into a tree on some remote logging trail. Would you want local EMTs who know the area well responding, or would you just prefer to wait out there in 5 degree weather while some non local Paramedics get lost repeatly while trying to get to you? Once they do get to you what are they gonna do prior to getting you into the ambulance? Pretty much the exact same thing we'd do. I know, Ive seen both sides of it doing ambulance clinicals with an ALS company and responding as an EMT and I didnt see anything done differently, except in the case where ALS handled it themselves the patients were suffering from hypothermia by the time they made it into the ambulance(almost the same thing on some car wrecks around here).


The poorest areas often get federal or state aid. Around here the poorest township has some of the best and most modern EMS equipment because they get federal aid and grants. Its the ones that arent as poor that have to pretty much fend for themselves because they dont qualify, and the public is usually less than enthusiastic about paying higher taxes for better EMS.

EMS is kind of a red headed step child when it comes to health care. People want the best hospitals staff and doctors, but EMS is generally an afterthought, especially in rural areas where people figure they are often better off just having someone drive them to the ER than waiting for an ambulance. I almost never see pediatric calls unless its something really bad because people just snatch the little ones up and drive rather than wait. Youd also be amazed at the condition of some of the patients that walk into the ED around here.

Significant trauma is not the by any stretch of the imagination the majority of what EMS responds to though. Sure, in this case transport to the hospital is what is needed. But we can do better than that for our medical patients. Is the dehydrated patient with some serious nausea and vomiting going to die during a BLS transport? Nah, probably not. But they would be a lot more comfortable going ALS, make no mistake.

 

[Veneficus]

Significant trauma is not the by any stretch of the imagination the majority of what EMS responds to though. Sure, in this case transport to the hospital is what is needed. But we can do better than that for our medical patients. Is the dehydrated patient with some serious nausea and vomiting going to die during a BLS transport? Nah, probably not. But they would be a lot more comfortable going ALS, make no mistake.

I would argue that ALS can make a difference in trauma.

In addition to decompressing a tension pneumo, which can be life saving, and ALS provider may not be as apt to over triage to airmed and cost the patient and the system 10s of thousands of dollars.

 

[usalsfyre]

Well depends on what you mean by care, the faster you get them to a hospital, the faster they get definitive care. If you are substantially delaying their transport because you insist on having Paramedics take them, are you giving them better faster care?



So why is this volly department only responding to 10% of the calls? Is this all they are dispatched to, or all they respond to when dispatched? Either way something doesnt make sense. As for beating them to the scene, I can say that I personally have never seen that happen where Im at. Usually its a substantial wait before ALS gets there.

Imagine its winter and someone crashes their snowmobile into a tree on some remote logging trail. Would you want local EMTs who know the area well responding, or would you just prefer to wait out there in 5 degree weather while some non local Paramedics get lost repeatly while trying to get to you? Once they do get to you what are they gonna do prior to getting you into the ambulance? Pretty much the exact same thing we'd do. I know, Ive seen both sides of it doing ambulance clinicals with an ALS company and responding as an EMT and I didnt see anything done differently, except in the case where ALS handled it themselves the patients were suffering from hypothermia by the time they made it into the ambulance(almost the same thing on some car wrecks around here).


The poorest areas often get federal or state aid. Around here the poorest township has some of the best and most modern EMS equipment because they get federal aid and grants. Its the ones that arent as poor that have to pretty much fend for themselves because they dont qualify, and the public is usually less than enthusiastic about paying higher taxes for better EMS.

EMS is kind of a red headed step child when it comes to health care. People want the best hospitals staff and doctors, but EMS is generally an afterthought, especially in rural areas where people figure they are often better off just having someone drive them to the ER than waiting for an ambulance. I almost never see pediatric calls unless its something really bad because people just snatch the little ones up and drive rather than wait. Youd also be amazed at the condition of some of the patients that walk into the ED around here.

So essentially you are arguing that the only reason to keep the volley system in place is because you're already there? Not a particularly strong argument. Most rural systems internationally have a volley first response component, this is not what anybody is arguing. I'm curious why your so intent on keeping the mediocre status quo in place though.

 

[Tigger]

I would argue that ALS can make a difference in trauma.

In addition to decompressing a tension pneumo, which can be life saving, and ALS provider may not be as apt to over triage to airmed and cost the patient and the system 10s of thousands of dollars.

No doubt this is true, I just see BLS being more worthless on medical calls than trauma. A cab is better half (most of) the time.

 

[Brandon O]

No doubt this is true, I just see BLS being more worthless on medical calls than trauma. A cab is better half (most of) the time.

If BLS is worthless to these patients, then so is the triage nurse.

 

[Veneficus]

If BLS is worthless to these patients, then so is the triage nurse.

Only if her education does not permit her to be better at it.

All Basic interventions end at "transport to the ED."

The triage nurse has the ability to send somebody back to see the doctor immediately in the ED, have them wait until other patients are taken care of first, and in some institutions, even refer them to fast track or urgent care.

A basic cannot make a patient wait and respond to other calls based on presenting acuity.

A basic cannot refer to anywhere other than the ED.

It is not that I am anti basic, it is that "basics" need to step up their game a lot in today's medicine. Their skills are minimal and some nearly obsolete.

 

[Brandon O]

Only if her education does not permit her to be better at it.

All Basic interventions end at "transport to the ED."

The triage nurse has the ability to send somebody back to see the doctor immediately in the ED, have them wait until other patients are taken care of first, and in some institutions, even refer them to fast track or urgent care.

Sure. But just like for an EMT, they're all going to end up seeing the doctor eventually. Likewise, most of an EMT's patients will end up going to the ED, but he can ensure that transport happens at a high or low priority; with ALS intervention, air transport, or other specialty resources; with an appropriate destination hospital which can provide the most appropriate care; with hospital pre-notification of the need for trauma, stroke, or other protocols; and with a transfer of care that allows for the immediate delivery of necessary care and conveys important information that would otherwise have been unavailable. And when patients are reluctant to be transported at all, he can decide how strongly to lean on them and encourage it. He can also advocate for the patient in any number of ways, although that may be beyond the current discussion.

It is not that I am anti basic, it is that "basics" need to step up their game a lot in today's medicine. Their skills are minimal and some nearly obsolete.

I know we've hashed over this before, and I hate to get into a neverending debate due to terminology. My point is merely that when I say "BLS," I mean this fundamental process of prehospital assessment and the resulting creation of an appropriate plan of care. Even when providing few actual interventions, this is useful stuff. I recognize your point that in practice, most current BLS providers may not have the training to do this very intelligently, but that doesn't mean the concept itself is flawed. Likewise, I appreciate Tigger's emphasis on early palliative measures, and I do wish that those were available at the BLS level, but again, it doesn't invalidate the importance of this process.

 

[Veneficus]

Sure. But just like for an EMT, they're all going to end up seeing the doctor eventually. Likewise, most of an EMT's patients will end up going to the ED, but he can ensure that transport happens at a high or low priority; with ALS intervention, air transport, or other specialty resources; with an appropriate destination hospital which can provide the most appropriate care; with hospital pre-notification of the need for trauma, stroke, or other protocols; and with a transfer of care that allows for the immediate delivery of necessary care and conveys important information that would otherwise have been unavailable. And when patients are reluctant to be transported at all, he can decide how strongly to lean on them and encourage it. He can also advocate for the patient in any number of ways, although that may be beyond the current discussion.

I think you considerably overestimate the amount of BLS providers who can do any of this effectively much less efficently.

I agree they should be able to. But should be and are currently have a wide divide.

I know we've hashed over this before, and I hate to get into a neverending debate due to terminology. My point is merely that when I say "BLS," I mean this fundamental process of prehospital assessment and the resulting creation of an appropriate plan of care. Even when providing few actual interventions, this is useful stuff. I recognize your point that in practice, most current BLS providers may not have the training to do this very intelligently, but that doesn't mean the concept itself is flawed. Likewise, I appreciate Tigger's emphasis on early palliative measures, and I do wish that those were available at the BLS level, but again, it doesn't invalidate the importance of this process.

I actually think we agree on the concept here, we simply differ on the details.

 

[Brandon O]

I actually think we agree on the concept here, we simply differ on the details.

I think so. The principle and purpose behind BLS care is invaluable. Whether or not most BLS providers are successfully providing this is a different matter.

 

[Bullets]

I think you considerably overestimate the amount of BLS providers who can do any of this effectively much less efficently.

I agree they should be able to. But should be and are currently have a wide divide.

I agree with your issues regarding BLS, but as i illustrated discussing the NJ pain management at the ALS level, in some systems even those who may have the knowledge and ability simply arent ALLOWED to do this stuff. If i wanted to notify the hospital of a patients condition, i would have to tell my dispatcher what i needed to say and hope that gets relayed accurately, which it rarely ever does. I did the leg work to find the phone numbers to the various "bat phones" at the hospitals in my area, but was always met with suspicion when i asked.

There also seems to be a reluctance in private practice doctors to act as a treatment facility for anything more then the sniffles. I have taken more and more patients out of doctors offices, patients who drove themselves to the office, but now need and ambulance to take them to the hospital for high blood pressure. Or i have had patients RMA and decide to follow up with their PMD only to be called the next day for the same patient.

If there is a place for BLS in this healthcare world, not only does it require a change at the BLS level, but also a change in the way Doctors down view their domain. One of the only things it think EMS in NJ has right is that ALS is based and employed by the hospital. This would indicate that the hospitals understand that their services are needed beyond the doors of the physical building and can be brought to the patients home. A patient shouldnt and doesnt have to wait until they are on property to begin recieveing care from the hospital. Alas that doesnt seem to be the case in most agencies

 

[Veneficus]

I agree with your issues regarding BLS, but as i illustrated discussing the NJ pain management at the ALS level, in some systems even those who may have the knowledge and ability simply arent ALLOWED to do this stuff. If i wanted to notify the hospital of a patients condition, i would have to tell my dispatcher what i needed to say and hope that gets relayed accurately, which it rarely ever does. I did the leg work to find the phone numbers to the various "bat phones" at the hospitals in my area, but was always met with suspicion when i asked.

There also seems to be a reluctance in private practice doctors to act as a treatment facility for anything more then the sniffles. I have taken more and more patients out of doctors offices, patients who drove themselves to the office, but now need and ambulance to take them to the hospital for high blood pressure. Or i have had patients RMA and decide to follow up with their PMD only to be called the next day for the same patient.

If there is a place for BLS in this healthcare world, not only does it require a change at the BLS level, but also a change in the way Doctors down view their domain. One of the only things it think EMS in NJ has right is that ALS is based and employed by the hospital. This would indicate that the hospitals understand that their services are needed beyond the doors of the physical building and can be brought to the patients home. A patient shouldnt and doesnt have to wait until they are on property to begin recieveing care from the hospital. Alas that doesnt seem to be the case in most agencies

I think you are describing 2 seperate problems.

The first is access and payment for care.

The second is a philosophical divide on the purpose of EMS.

Some years ago, a philosophical divide of the purpose of EMS was established in the US.

One side was the idea that EMS would be an extension of the hospital and extend the hospital's care to the field.

On the other was that EMS could never measure the ability of physicians and therefore they should simply rapidly transport patients to the hospital.

As time goes on it becomes more evident that EMS as an extension of the health system is the only sustainable and valuable role for them.

Because of the fractured nature of US EMS, what you describe is some places still operating on outdated EMS concepts.

But it spans the whole divide. There are services embracing successful EMS practices modeled originally by other nations. There are services that are still just a glorified hearse and might as well be a funeral home service and everything in between.

As an interesting bit of trivia, the original idea of extending the hospital to the field was called the Franco-German form of EMS.

The rapid response and drive to the hospital form was called the US form of EMS.

The only places that still use the originally "US" idea are parts of the US, developing and underdeveloped nations.

As emergency medicine EMS fellowships, tactical physician positions, rapid physician response vehicles become more prevalent in the US, I think it is a logical conclusion than a continued shift towards more physician field providers in the US is inevitable.

When you consider that those physicians are best suited to the critical but savable patient populations, it will further marginalize basic EMS providers to more and more transport and less care of acute emergencies.

As well, when the inevitable changes in reimbursment and malpractice permits more physicians to treat and release, house calls, preventative medicine and the like, the basic EMT will essentially become the rural volunteer or urban taxi to the most appropriate facility.

 

[mycrofft]

I liked hogwiley's initial reply

...because it brings (one of) my pet peeve(s) up; namely, take the toughest poorest slimmest situation and remember that, because we can't all live in the " 'burbs and urbs".

The reality of the supply of provider candidates, the supply of responders, the supply of equipment and supplies, transport times, numbers and types of cases, must be taken into account before we start cookiecuttering (??) decisions. In many (not most) areas in say NW North America, there is no EMS system as we like to fall back on for our archetypes here.

ANY training is better than none, not only because of aid rendered, but because you learn what NOT to do, and when to call/send for help. Each level better than basic first aid is an improvement but only if logistics and infrastructure support them, or they are granted some sort of independent duty status...or just go in and do it without any sanctions at all.

 

[hogwiley]

I personally dont care if the EMT Basic certification was eliminated. Like probably everyone here, Ive seen more than a few EMT Basics that scare the crap out of me, and EMS would certainly benefit from having them either go for more training and prove a higher level of competency, or find another job/hobby.

Im simply pointing out that there is in fact a reason the people who make such decisions have not done so. Mainly the problem is cost. People are only willing to spend so much on EMS, whether we think that is a wise decision or not, its the reality. Having two paramedics on every EMS call everywhere in the US is generally cost prohibitive, and probably has limited value.

There seems to be a law of EMS that says everyone seems to think the level of training THEY are at should be the minimum level of training. I just find it amusing when newly minted Paramedics who were EMTs for years suddenly decide that we dont need EMTs the minute they become a Paramedic.

 

[Bullets]

As well, when the inevitable changes in reimbursment and malpractice permits more physicians to treat and release, house calls, preventative medicine and the like, the basic EMT will essentially become the rural volunteer or urban taxi to the most appropriate facility.

And thats fine, if the EMT becomes a true ambulance driver to a Medic and a MD or RN that is a role they can fill. the EMT really would do IFT work and maybe some non-transporting first responder stuff, stop bleeding, start compressions. Most critical care trucks are driven by EMTs around here and are gophers for the ALS crew.

In cities, most fire chiefs have a driver for their truck, the same could be true of your physician go-teams or something. But as a 911 provider, the training isnt where it needs to be for the EMT to be an effective option.

Now to get around the politics

 

[TransportJockey]

And thats fine, if the EMT becomes a true ambulance driver to a Medic and a MD or RN that is a role they can fill. the EMT really would do IFT work and maybe some non-transporting first responder stuff, stop bleeding, start compressions. Most critical care trucks are driven by EMTs around here and are gophers for the ALS crew.

In cities, most fire chiefs have a driver for their truck, the same could be true of your physician go-teams or something. But as a 911 provider, the training isnt where it needs to be for the EMT to be an effective option.

Now to get around the politics

And to be honest, the biggest groups who would oppose this kind of real advancement would be the firefighter unions and the volunteer departments.

 

[Veneficus]

...because it brings (one of) my pet peeve(s) up; namely, take the toughest poorest slimmest situation and remember that, because we can't all live in the " 'burbs and urbs".

It is not that they can't, it is that many choose not to. Again when you look at the rest of the world, you see concentrated population centers and a very small rural population.

Those rural populations rely on either self sufficency or volunteers.

The long time rural populations know they cannot expect the same services as the urban populations. They accept when the end has come.

They do not waste resources on illusion or pretending they have or can afford what their urban counter parts do.

In the Pacific NW (but not exclusively), you have a phenomenon of people "wanting" to move out of the burbs and urbs without being willing to give up the benefits of social cohabitation. Then they complain they cannot afford to move these services to a small consumer base in an economical way.

People don't understand, when you choose to isolate yourself, you don't realy get to pick what aspects of isolation you want and those you don't.

Simply, you cannot have your cake and eat it too.

...ANY training is better than none, not only because of aid rendered, but because you learn what NOT to do, and when to call/send for help.

I don't think anyone disputes the usefulness or need of a minimally trained provider for out in the sticks.

But the usefulness of the EMT-B in other environments comes down to being cheaper than a medic or totally out of their element. What is the point of paying for an EMT and all the emergency equipment on a BLS ambulance for the dialysis derby?

The only part of EMt-B training applicable is the ability to take a set of vitals. Even that is disputable as it other even lesser trained providers can do the same at a fraction of the cost.

The reason it takes an ambulance at all is because somebody makes a lot of money for charging medicare/medicade for "medical transport" when a simple taxi with a cot and 2 orderlies would do.

How much do you think you would have to pay 2 untrained laborers to pick somebody up, put them on a cot, and drive them anywhere they needed or wanted to go at any given time?

 

[NYMedic828]

How much do you think you would have to pay 2 untrained laborers to pick somebody up, put them on a cot, and drive them anywhere they needed or wanted to go at any given time?

$5 for the first mile and $1.50 for every mile after that.

 

[Veneficus]

$5 for the first mile and $1.50 for every mile after that.

Exactly.

Saves a lot of money carting the dialysis patient 3 times a week at the BLS rate. Imagine the savings over a year across the US.

 

[NYMedic828]

Exactly.

Saves a lot of money carting the dialysis patient 3 times a week at the BLS rate. Imagine the savings over a year across the US.

Especially considering the cost of their transport and treatment from the receiving facility partially comes out of my own paycheck... Yayyy liberalism.

 

[11569150]

I would just like to point out that there are places in rural US that are still entirely bls volunteer ambulance services. I would like to use covelo, ca as an example: it is an hour and a half drive to the nearest town from there let alone to the nearest hospital and als ambulance. The folks up there are mostly dope growers and natives. Handfuls of ambulance companies have looked at staffing that town but no one will touch it because its so secluded. They usually rely on air transport if the weather is nice other than that hour plus als rendezvous. Now, doing away with the emt-b cert entirely would mean the FD would have to figure out a way to motivate their volunteers into taking expensive classes that are hours away and all for something that they get no financial reimbersment for in the first place. Covelo is lucky to even have the service they have right now and forcing bls out of the picure would just elimate healthcare there entirely. Just saying something to think about.