ALS or BLS?

[rmabrey]

As many of you might know, New Jersey runs an EMS system where BLS responds via ambulance and ALS responds in a chase unit. EMS crews are always EMT/EMT and Medic/Medic.

As an EMT, I admit that there are some of us that lack the skill and knowledge to perform effectively. What an EMT does is basic, hence why called and EMT Basic. I believe what makes a good EMT is an EMT that can make a baseline assessment and properly prepare the ALS team when they walk through the door with a full report. There are some of us that do this and do this well, others unfortunately no.

At the same time, they way many ALS teams function can be discouraging to a point that almost makes the EMTs fell like stretcher jockeys. When ALS walks through the door and you give vitals, report and history, and they just disregard it. It almost feels as if our assessment is not wanted anyway. Does anyone actually trust us?

The more times you aske a question, the more the answer changes.

 

[ZombieEMT]

While I do admit, I have done the same in the past with first responders transferring care to EMTs, I still understand why some EMTs might become discouraged. When we provide a good assessment at the BLS level and good report to the ALS team on arrival, it would be nice to know they honor our report. I do understand that they want to be accurate and need their own assessment, but it is a pain when you are taking a BP through the door and the first thing they do is redo it.

I want to clarify, that not all medics are like this. It seems to be a trust thing at some point. Many of the medics that I get on a regular assessment due trust and honor my assessment, but when I am new to the area or there are new medics to my area, we see this again and again.

 

[Clipper1]

While I do admit, I have done the same in the past with first responders transferring care to EMTs, I still understand why some EMTs might become discouraged. When we provide a good assessment at the BLS level and good report to the ALS team on arrival, it would be nice to know they honor our report. I do understand that they want to be accurate and need their own assessment, but it is a pain when you are taking a BP through the door and the first thing they do is redo it.

I want to clarify, that not all medics are like this. It seems to be a trust thing at some point. Many of the medics that I get on a regular assessment due trust and honor my assessment, but when I am new to the area or there are new medics to my area, we see this again and again.

No Paramedic should ever start an intervention, especially medications, unless they have confirmed or witnessed the vital signs. This is not only true for EMS but also for other health care professionals like RNs. Even doctors have been known to confirm a BP and other vital signs themselves. No one should ever feel insulted when it is for patient safety. It is also the Paramedics *** on the line and who is responsible. So, put the egos aside.

 

[ZombieEMT]

I understand everyone needs to make their own assessment, but this is the complaint I have heard from other EMTs. Should this be the process that takes place? If I am taking a blood pressure, as the medic comes through the door, it should not have to be redone immediately just to start treatment, we work in a field that we should all be able to trust each other. However, it is unfortunate that all the way up the line it happens, whether its EMT to Paramedic, Paramedic to Nurse, or Nurse to Doctor.

 

[Clipper1]

I understand everyone needs to make their own assessment, but this is the complaint I have heard from other EMTs. Should this be the process that takes place? If I am taking a blood pressure, as the medic comes through the door, it should not have to be redone immediately just to start treatment, we work in a field that we should all be able to trust each other. However, it is unfortunate that all the way up the line it happens, whether its EMT to Paramedic, Paramedic to Nurse, or Nurse to Doctor.

Where do you chart the vitals? Do you chart them on the Paramedic's PCR? Since you are arriving at different times, how well do you and the Paramedic know each other?

Your set of vitals is great to get the ball rolling but from that, if a Paramedic is to start an intervention he should confirm vitals. Vital signs can also change quickly in the acutely ill.


In court when asked about the vitals, the Paramedic can not say he treated off the vitals from some EMT with another company who he did not know. He bears the full responsibility for his actions.

If you actually knew the consequences of performing an intervention without checking vitals for confirmation, you would see how strange your argument sounds. True professionals are not intimidated by someone else checking and may even insist on it.

PATIENT SAFETY. PATIENT SAFETY. Absolutely nothing wrong with more ears checking BPs. This should also hold true for checking medications but if the Paramedic only has an EMT partner, that is difficult.

 

[ZombieEMT]

I am refering to a Medic that withnesses and EMT obtaining a BP as the Medic walks through the door, and the first thing they do is redo the BP. I answer your question with another, why can't a medic document BLS vitals in their report and that BLS assessed the vitals? I understand that as a liability issue, Medics perfer to get their own before treatment, but it is a trust issue. The ALS crew does not trust the assessment of the BLS crew. With that you are saying, does that mean when you are a Medic/Medic team in other areas, that you redo a blood pressure after your Medic partner has done it before your treat the patient.

I do understand where people are coming from, like I said, I am quilty of this myself. The company I work for covers an area where they provide first responders, and I always reassess for myself on arrival. I just wanted to point out, that some BLS EMTs have stated before that they dont feel trusted and feel useless.

 

[Medic Tim]

I am refering to a Medic that withnesses and EMT obtaining a BP as the Medic walks through the door, and the first thing they do is redo the BP. I answer your question with another, why can't a medic document BLS vitals in their report and that BLS assessed the vitals? I understand that as a liability issue, Medics perfer to get their own before treatment, but it is a trust issue. The ALS crew does not trust the assessment of the BLS crew. With that you are saying, does that mean when you are a Medic/Medic team in other areas, that you redo a blood pressure after your Medic partner has done it before your treat the patient.

I do understand where people are coming from, like I said, I am quilty of this myself. The company I work for covers an area where they provide first responders, and I always reassess for myself on arrival. I just wanted to point out, that some BLS EMTs have stated before that they dont feel trusted and feel useless.

If the emt is attached to my pcr I have no problem charting the vitals and crediting them for it. if not I may make a note of it in my narrative. If I didn't do it or my partner/whoever else is attached to the pcr didn't then it doesn't get charted as vitals.

that said if I am going to perform an intervention I will most likely check the vitals myself as everything falls back on me.

When I was working as an EMT it initially annoyed me as I thought the medics didn't trust me. After some time in the field and going through medic school I now realize why they did what they did and do it myself.

 

[chaz90]

I don't often run into this problem. Most of the time the assessment findings BLS passes on to me pretty much consist of "This patient is having chest pain, so....here you are." This makes it easy to start from nothing and do the entire assessment myself/with my partner.

In some cases, the EMT on scene first is excellent. When this happens and I trust them, I absolutely listen to what they have to tell me and don't necessarily jump to repeat vitals. I also aim not to repeat questions, but sometimes that's just the nature of the game.

I find that sometimes the questions I ask might be phrased slightly differently than what the EMT asked before me. Going back to the chest pain example, some will ask "Does anything change the pain?" I'm likely to follow that up with actual attempts at palpation while asking if their pain is changed and then having them inspire deeply while asking them the same.

 

[Jambi]

I get what HaleEMT is talking about. it's not that they're redone, it's when they're disregarded as useless. I take the approach of acknowledgement and thanking them for the assessment, information, and turnover, and ask if he or she remembers anything else to please tell me. I then reconfirm the assessment findings and get anything extra that I'm looking for.

This typically goes like this: "my colleague tells me...," or Mr/Mrs/Ms so and so tells me...," you're having chest pain.

No there is no nice way of repositioning 12-lead patches that are on wrong, and some people get real butt hurt when it's done, so I just make a point of counting out ribs when I do it...it's hard to dispute the position after I just counted to the 4th or 5 intercostal space and/or traced the mid-clavicular, axillary, or mid axillary line...

 

[Akulahawk]

When it comes to vital signs, if the first responders (whatever level) have it documented and I can bring a copy of their report with me, I'm OK with holding off of re-doing vitals. I'll summarize certain parts of the report with/for the patient and ask them if that sounds right. Then I'll do my own assessment (because it's my backside if I don't) and I'll usually ask some general questions and often some pointed ones to help me figure out what's going on. Sometimes that helps out the first responders sharpen their own skills too. It's not that I don't trust them, it's more that I need to make sure my own backside is covered as well, and the better they are, the better their own backsides will be covered if something goes sideways...

 

[Btalon]

When I ask them for a set of vitals, they automatically reach for my monitor. When I say I'd like a manual BP, they look like a deer in the headlights.

I just passed my AEMT and am waiting on my license, but earlier this year signed on with a local agency as a basic with a medic partner at all times. One of the first calls I went on was this scenario, except it was a comment of getting vitals and I pulled out the bp cuff and they looked at me like I had 2 heads.

I work in a wilderness environment and we don't have monitors or anything needing batteries to help us, it's done the old fashioned way. I'm used to it and I think it helps me in the rig.

I really think it comes down to people getting used to the easy way to do things. Not that they are lazy, but what do you usually do when you get on scene, hook them up to the zoll and let it run. I'm just used to getting on scene and pulling out my bp cuff and stethoscope, we didn't get a pulse oximeter until 2 years ago and it's a rudimentary one.

Lets face it, you can hook them up, let it run and be doing something else, it is a plus and lets us accomplish more quicker, but basic skills are the foundation and shouldn't be lost.

 

[usalsfyre]

No Paramedic should ever start an intervention, especially medications, unless they have confirmed or witnessed the vital signs.

You should know always and never are the two most dangerous words in medicine. While I generally agree with you, I can think of several circumstances that required interventions including medications prior to vital signs. Either so I could even begin to obtain them or if I had waited to obtain a full set the patient wouldn't have HAD vital signs by the time we intervened.

 

[Clipper1]

You should know always and never are the two most dangerous words in medicine. While I generally agree with you, I can think of several circumstances that required interventions including medications prior to vital signs. Either so I could even begin to obtain them or if I had waited to obtain a full set the patient wouldn't have HAD vital signs by the time we intervened.

True. Using an AED might be one.

But I have also seen albuterol given to a "wheezing" patient with a HR over 200 just because it is "only albuterol" or someone took a number off the pulse ox as true. Or, a wrong path taken when the BP was way under the correct number.

 

[RocketMedic]

You should know always and never are the two most dangerous words in medicine. While I generally agree with you, I can think of several circumstances that required interventions including medications prior to vital signs. Either so I could even begin to obtain them or if I had waited to obtain a full set the patient wouldn't have HAD vital signs by the time we intervened.

Quoted for truth. Some things are ALS fixes and can be diagnosed very, very quickly. Does blood pressure particularly matter when you're looking at a hypoglycemic crisis, a lethal rhythm or an emergent airway?

 

[Tigger]

Lets face it, you can hook them up, let it run and be doing something else, it is a plus and lets us accomplish more quicker, but basic skills are the foundation and shouldn't be lost.

Right up until you get an inaccurate reading. I hate the cheesy "treat the patient not the monitor" line but if a relatively healthy looking patient comes back with a BP of 210/160, you can bet that a manual verification will be done. It seems like whenever I don't start with manual acquisition of vital signs that the LP gives some off the wall reading.

 

[DrParasite]

Not for nothing, but if you have competent BLS providers, than you should be able to trust their assessment. Based on what I hear on these forums, their BLS providers are neither experienced nor educated, and can't do anything without a paramedic looking over their shoulder giving them step by step direction.

I have had paramedics initiate interventions based on my report. The paramedics in questions had known me for years, worked alongside me, and the agency that we worked at had a pretty active QA person. Maybe we were the exception to the rule?

that isn't to say every paramedic took what I said as gospel. There are more than a few who ignored everything I said, did their own assessment, and treated accordingly. Usually they were newer medics, newer medics to the agency, or medics who didn't know me very well. Or they just didn't trust me, didn't like me, or didn't feel comfortable with my assessment skills. Oh well, I get paid by the hour, if they want to do the work all over again, that is their prerogative.

Actually, there was one time when a paramedic did that and it did piss me off. had a patient, who was a 30-40 yof known diabetic (I had treated and transported her for low BGL in the past), is altered, diaphoretic, and is found sitting on the couch. when the paramedic arrived, I asked them to check her BGL, and instead of checking her BGL, and giving her D50, and returning her to normal, he put her on the minitor, checked her vitals, and then checked her BGL, which was (shocker!!!) 34.

Work with the same ALS and BLS personnel, day after day, and they will trust you. but if you don't, and it's always a crap shoot on if the paramedic is competent, or the EMT can actually do his or her job, can you blame them for not trusting the report of the other?

 

[RocketMedic]

After quite a lot of thought and some experiences with the vicious downside of the EMT vs Paramedic question, I have reached a conclusion:

EMTs in my system are not responsible for patient care. At one agency, they are literally referred to as "EVOs", or "emergency vehicle operators". That is not to say that they are not involved in patient care, nor is it to say that they do not provide patient care, but they are not responsible for that care. The same is true in most ALS services- paramedics are in charge of what happens on the truck at all times. In many of those agencies, a paramedic must tech the call. This creates an environment that makes it difficult for an EMT to do anything other than EVO and ALS-assist. At my agency, an EMT is literally a talented bag-fetcher, gurney jockey, go-fer and assistant.

Now, I do not agree that EMTs should be limited to these roles. It's bad for professional development, it stifles the growth of critical decision-making, and it breeds an attitude of complacency regarding assessment and care. "They look fine" or "he looks sick" becomes the going depth of assessment, in exactly the same way as a nursing assistant will inevitably learn to recognize diseases. They learn medicine by direct observation, they practice medicine thirdhand with no chance of negative recriminations or accountability, and they do it all on a "vocational" education that wouldn't even let them set up a hoseline in fire school or a curling iron for profit. Despite this, people are smart, and they adapt. They work side-by-side with us, and we respect them as partners and as people. But that's where we hit a snag in this previously-workable relationship.

Many EMTs take this one career further and actively educate themselves, seek out advice from their coworkers and friends, and go to school. They become Paramedics and assume those responsibilities that they previously did not have. Most paramedics, myself included, are in this latter category. We saw what we could do as EMTs, we made a conscious decision that we wanted to do more and perform at a higher level, and we actively sought an education that would allow us to perform at a higher level and do more for our patients, with all of the attendant responsibility. There is nothing wrong with being an EMT with this attitude; they are absolutely vital to our operations as paramedics. A partner who wants to learn is an absolute joy to work with and enhances our patient care immeasurably. A partner who learns how to be a paramedic is not only helping us provide better care, they are providing better care themselves and they are helping themselves progress professionally. This is essentially a master/apprentice relationship by any other name, and is mirrored in other health professions (residents, etc).

On the other hand, many EMTs confuse this with a truly even division of responsibilities. They avoid and ignore higher education and revel in memes, mantras, the perception that EMS is a "family" where we must respect and outright honor the "blue-collar" or "workman" ethic and the noble ignorance of an EMT-Basic. They exist in a world where "everyone has EMT in their certification" or "there's no difference between a white patch and a gold patch". They may have the knowledge base of a paramedic or a doctor or a nuclear physicist, but they are functionally working as assistants. One of the most challenging days of my career to date was when I, as a newly-released paramedic, was informed by my temporary partner that I would be letting her run the calls, because she was "almost a Paramedic, but didn't want to deal with the hassle of upgrading and having to do all of the paperwork." As you can imagine, fellow professionals, this went over with me in exactly the same way as a surgical team would react to a first-year resident declaring that he would be leading the cardiothoracic surgery. These EMTs are everywhere, in every agency. They are "competent" in that they can perform tasks to standard, but they are the first to fall back on protocols, rules-of-thumb, mantras, and pedantic half-answers that equate to a punting of responsibility. They may be able to recount how they saved their paramedic partner from the embarrassment of disconnecting an IV still hanging from the roof or an oxygen line not yet plugged into a portable, but they are not willing to accept real responsibility for patient care, because they have (for whatever reason) not invested in themselves. After all, how much effort and time does it really take to stay current on EMT skills, and why would they invest time in learning why or how when they could say "treat the patient not the monitor" or "BLS before ALS" and simply slide the hard questions to their paramedic?

As a paramedic, I assume that my partners are competent, and I ask them a question at the start of our working relationship- what do they want? If they tell me that they would like to be actively involved in patient care and that they are interested in learning with me, I treat them as if they are paramedics. That is not to say that I let them do things that are out of their scope of practice, but I treat them and their opinions with the same credence and respect that I would hope mine are treated with. I invest time in discussing EMS with them, and I show them what I know about our protocols, equipment and techniques. I explain my actions and ask them genuine questions about what we and I could have done better, and I give real weight to their opinions. I keep criticism entirely constructive, and I often find that I learn more than I have taught. This is how I was treated as an EMT, and I feel like it made me a better paramedic.

If, on the other hand, my partner tells me that they have no interest in progressing beyond being an ambulance driver and an EMT in terms of their practice, they will find themselves doing exactly that. They will drive, they will assist, and they will help assess and treat within their scope of practice. They may learn, but they will not be the recipients of my undivided attention. There is very little point in trying to teach someone who does not want to learn; if I wanted to do that, I'd be teaching in a high school. These are the EMTs who are the first to criticize "discrimination against the white patch" and become defensive about "ambulance drivers", perceived slights against EMTs and who perpetuate the negative stereotypes that abound throughout our industry. Even worse, these same people become paramedics, and they maintain that attitude. I really do feel that these people are the reason that we have problems with issues like appropriate pain management, poor assessments and lackluster patient care.

If someone is determined to remain an EMT, I respect that. I simply ask that they open their minds and learn to the limits of their scope of practice, and not simply revel in ignorance. At my agency, I recently worked with a very, very senior EMT. He expressed a desire to learn more about the ventilator we carry, and I showed him, and I learned quite a bit from him. That is learning. That is the way that things are supposed to work. It was a mutually-beneficial relationship.

There is nothing noble about a patient who suffers because of substandard care at any level. For an EMT to criticize a paramedic when they themselves are unwilling to assume real responsibility is simply foolish.

 

[RocketMedic]

Further consultation has led me to realize what I shall call the Veneficus Proof: There is no point in trying if they do not want to learn. There's no reason to place my job in danger by playing siren for the wave of changes that will wash away the nonbelievers.

It's time to just smile and nod whenever someone spouts off about how horrible I am as a person.

 

[TransportJockey]

Further consultation has led me to realize what I shall call the Veneficus Proof: There is no point in trying if they do not want to learn. There's no reason to place my job in danger by playing siren for the wave of changes that will wash away the nonbelievers.

It's time to just smile and nod whenever someone spouts off about how horrible I am as a person.

You horrible horrible.... Err never mind lol. You don't seem that bad.

 

[RocketMedic]

Im probably the worst paramedic at EMSA to work with. You know, with the letting my partners be EMTs and all. Maybe I should just go drinking with them instead.