Any states besides NJ that only have hospital-based ALS?

[VFlutter]

Depends on the system. I've worked in at least one where this was the focus.

I am sure there are some systems out there but the majority fall short. I think AUS/EU EMS is a good model of what can be accomplished.

 

[reaper]

No, not to things like sickness, weakness , abdominal pain, falls with no LOC, minor MVC, and what they call "emergency transport" which can be stuff like bouts of colitis, feet swelling, bloody nose, or any of the myriad of ridiculous reasons people call 911

*This is the thinking that makes needing a medic on scene even more important! Sickness calls are some of the worst pts. "Weakness", why are they weak? Cardiac, sepsis, dehydration? Abd pain? What is the cause? "Falls", why did they fall? Syncople episode? " minor mvc"? Have seen many deaths from these. All from bad assessments.*

All of our dispatchers are EMDs, its pretty much a requirement to work at any PSAP or PSDC.

*Most systems are EMDs. This is nothing spectacular and dispatch mistakes happen all the time.*

But for an unconscious, regardless of the cause, we get ALS. Besides the obvious chest pain, LOC, breathing problem, arrest, allergic reaction, diabetic, we also get ALS on any OB call, any vehicle roll-over, and any time the dispatcher isnt sure what is going on

As said previously, this allows the ALS to respond, do an assessment and then determine if this is something they need to treat or something that can be turffed to BLS and they can become available. In my suburban town we have two medic units (P/P) within 5-10, 2 more at 15 and then like 4-5 units at 20. We obviously share our medic truck with a few surrounding towns, but we are the busiest system by far. In the three years i have worked here there was one time i needed ALS and did not have them.

In some cities it can be as many as a 6-7 als trucks being supported by 12-15 bls units

Every pt deserves an advanced assessment. Most that argue that this system works, have never scene a good system work. There is a reason why some of the best systems in the country do not use this model of EMS. It is not in the best interest of the pt. It is only in the best interest of the bean counters.

We have several ex NJ medics working here. They all hated that system and are amazed at what is done else where.

 

[Tigger]

You basically just said no one else in the world does what NJ does, but then refuted yourself. Whether the highest level is a physician or a IC paramedic, there is a stepwise approach unlike most of the US which likes to use a shotgun approach and send their highest level of care to every call even though the overwhelming majority do not need it. It's silliness. Maybe a lot of patients need pain management, but it doesn't mean they need fentanyl and even if so, it doesn't mean they need a medical provider also trained in intubation, IVs, cardioversion, etc. to give it. (Afterall, pain management is probably one of the safest treatments in the back of the ambulance.)

[If a moderator wants to combine my 3 separate responses into one post, go ahead.]

Yes, there is a stepwise approach. However, in the rest of the world the lowest level of provider is capable of dealing with the vast majority of calls and only requires a physician or an intensive care paramedic rarely.

This would be in contrast to New Jersey, where the lowest level of provider cannot handle the majority of calls. Handling is not synonymous with transporting to the hospital mind you. A taxi can do that. Handling implies the providers have the knowledge and tools necessary to treat the patient, or if nothing else to mitigate the unpleasant symptoms the patient is experiencing during transport.

There is no system in the developed world where the many (possibly the majority) of frontline providers have no more education than a HS diploma and an 120 hour course.

 

[NomadicMedic]

We have several ex NJ medics working here. They all hated that system and are amazed at what is done else where.

The same here. We just hired several medics from NJ and they took some "retraining" to get used to doing things our way.

 

[Bullets]

Every pt deserves an advanced assessment. Most that argue that this system works, have never scene a good system work. There is a reason why some of the best systems in the country do not use this model of EMS. It is not in the best interest of the pt. It is only in the best interest of the bean counters.

We have several ex NJ medics working here. They all hated that system and are amazed at what is done else where.

Your correct, i have never scene a good system work. However i have never seen a good system work either. I worked in PA initially during college and i think that state is even more of a Charlie Foxtrot then NJ is. Those are the only two systems that I will speak about because they are the only two i have experience with, everything else i know about other states is anecdotal or hearsay and i will not speak to those systems.

The bean counter excuse is not a valid one in NJ, as most municipalities are served by non-billing BLS agencies. In most of the state when a non-billing BLS agency and billing ALS agency respond, the ALS agency get all the money from the insurance. The BLS recieves no funds from patients.

I fully admit that NJEMS has problems, but the vast majority are at the extreme ends of the spectrum. BLS is its own worst enemy and all providers are hampered by DOH, who are the whipping boy of the state gov't.

And the NJ Association of Paramedics like things the way they are

 

[ZombieEMT]

Every patient does deserve an appropriate assessment, but that assessment does not come from a paramedic. That assessment and treatment will come from a hospital. Even in a system with medic/medic transporting ambulance, the end goal is definitive care at a hospital. If the patient does not need ALS intervention, or ALS can not provide that treatment why waste the resource.

As for all the bean counter statements, I think that is a big part of it. Are we going to bill patient's and/or insurance companies an excessive amount. I know I would rather take the 5-15 minute transport if I was only having minor abdominal pain and be assessed at hospital then be billed by ALS then be billed by the hospital. Whether or not we like it, EMS is a business and a lot focuses around the dollar.

It helps the economy as well. Paying to have medics in every service and municapality when not needed would cost billions of dollars in the state.

One thing that I think people need to remember about NJ is how densely populated we are. The majority of the state is less then 10 minutes to the closest emergency department. We are not a rural state with average transport (or response times) ranging 30+ minutes.

 

[medicsb]

Every pt deserves an advanced assessment. Most that argue that this system works, have never scene a good system work. There is a reason why some of the best systems in the country do not use this model of EMS. It is not in the best interest of the pt. It is only in the best interest of the bean counters.

Which "best" systems are these and can you back it up with data?

Don't fool yourself into thinking because most places don't do "it" that it is because it has been shown to be not good. Most of those decisions are political or based on a hunch that "more" is better. A medic on every ambulance has never been shown to be a better model, it has just been assumed that it is. We do know that system with more medics per capita tend to not be as skilled and we know that in medicine, experience (in terms of frequency, mainly) is associated with better outcomes for patient. I will never understand why so many in EMS blatantly ignore that. Though, I guess it is because their livelihood is dependent on such ignorance?

This would be in contrast to New Jersey, where the lowest level of provider cannot handle the majority of calls. Handling is not synonymous with transporting to the hospital mind you. A taxi can do that. Handling implies the providers have the knowledge and tools necessary to treat the patient, or if nothing else to mitigate the unpleasant symptoms the patient is experiencing during transport.

Wut?! Most patients need nothing more than some psychosocial support and a ride. The fact that most need only transport is the source of most complaints from EMSers about EMS. If you skim off the one that only need a ride, after that the majority probably need tylenol (ok, fentanyl for some) or zofran ODT... and a ride. The number of patients needing anything beyond that probably comprises around 1/5 of all patients (probably less).

Anyhow... I would agree that an EMT is not ideal and that standards need to be raised, but not by replacing with them paramedics (unless you're going to use something like the Canadian version of a paramedic, which is closer to an AEMT/EMT-I in terms of scope of practice).

 

[DrParasite]

The same here. We just hired several medics from NJ and they took some "retraining" to get used to doing things our way.

and I bet if we took some DE medics, it would take some "retraining to get used to doing things our way". Doesn't make your way better than theirs, but it's YOUR way.

I've worked in EMS systems in upstate NY, NJ, and PA. In NY and PA, the EMTs were absolutely useless without a paramedic to hold their hand. They never saw sick patients. We also have several NYC medics who lefts NYC to NJ (we pay a lot better). they also required "retraining," and some didn't cut it (including a former clinical coordinator from NYC).

I've heard nothing but bad things about MD, DC, and Cali EMS.

Is NJ a perfect system? absolutely not. There are quite a few problems with it (primarily related to funding and staffing), as well as the NJFAC which is the cause of many of the existing problems. But we aren't as bad as some ignorant opinion tend to think. and we pay our providers better than many many other states.

remember, evidence based medicine is the new thing; so if there is no evidence to back up your claims, maybe you are still talking out of your heiny?

Wut?! Most patients need nothing more than some psychosocial support and a ride.

now there you go throwing that common sense and reality into the argument. that will not be tolerated here, as certain people will take it as a personal attack!!!

 

[NomadicMedic]

Is NJ a perfect system? absolutely not. There are quite a few problems with it (primarily related to funding and staffing), as well as the NJFAC which is the cause of many of the existing problems. But we aren't as bad as some ignorant opinion tend to think. and we pay our providers better than many many other states.

So, "quite a few problems" and the fact that the volunteer first aid squads keep ALS hamstrung is negated by the fact that "New Jersey pays better?"

 

[DrParasite]

So, "quite a few problems" and the fact that the volunteer first aid squads keep ALS hamstrung is negated by the fact that "New Jersey pays better?"

Not at all.... but I don't work in a perfect system, nor do I pretend to... do you?

 

[NomadicMedic]

Nope. Not even a little.

But I certainly don't say that paying more than anybody else makes it okay.

And while the New Jersey medics who've come to work in my system all say they've taken a pay cut, they are more impressed with our system's clinical skills, excellent relationships with the BLS providers and the hospitals, the amount of freedom in their practice, and the fact that they're not getting slaughtered running 30 calls in a 24 hour shift.

And as an aside, we've had a slew of New Jersey paramedics interview for positions here. The majority of them cannot pass our initial interview.

So… You know… There's that.

 

[DrParasite]

not at all, but the high pay is an upside to the NJ system.

Maybe the ones who can't pass your interview are the ones we don't want in NJ? After all, the good ones stay with us and don't go out, so they never bother to interview with you for less money. and I don't know of a single DE paramedic who has gotten hired at my current or former EMS agency. so you know, there is that.

and most places don't run 24 hour shifts, and those that do don't run 30 calls in a shift.

 

[medicsb]

Nope. Not even a little.

But I certainly don't say that paying more than anybody else makes it okay.

And while the New Jersey medics who've come to work in my system all say they've taken a pay cut, they are more impressed with our system's clinical skills, excellent relationships with the BLS providers and the hospitals, the amount of freedom in their practice, and the fact that they're not getting slaughtered running 30 calls in a 24 hour shift.

And as an aside, we've had a slew of New Jersey paramedics interview for positions here. The majority of them cannot pass our initial interview.

So… You know… There's that.

No where in NJ do medics work 24 hour shifts that I know of. 18s are generally the max. There have been medics from DE that have come to work in NJ and I know some who work BLS in DE and have their share of stories. Ho-hum.

 

[firecoins]

I had no problems with Jersey ALS. its not a perfect system. I have worked in three systems and they all sucked somehow.

NJ ALS are too restricted and should get a bit more freedom.

Yes every pt deserves an advanced assessment but we cant do everything patients needs assessment wise in the prehospital environment. We cant get pathology and radiology involved prehospitally. Not yet at least. Soon if "they" will pay for the equipment and training. Until than you just got to transport. We are not the end all be all on who gets to go the ER.

 

[Bullets]

So, "quite a few problems" and the fact that the volunteer first aid squads keep ALS hamstrung is negated by the fact that "New Jersey pays better?"

The volunteer squads do not hamstring ALS. They have very little influence on each other. It's the DOH that restricts ALS and BLS collectively.

BLS only restricts themselves and its infuriating

 

[Tigger]

Wut?! Most patients need nothing more than some psychosocial support and a ride. The fact that most need only transport is the source of most complaints from EMSers about EMS. If you skim off the one that only need a ride, after that the majority probably need tylenol (ok, fentanyl for some) or zofran ODT... and a ride. The number of patients needing anything beyond that probably comprises around 1/5 of all patients (probably less).

Anyhow... I would agree that an EMT is not ideal and that standards need to be raised, but not by replacing with them paramedics (unless you're going to use something like the Canadian version of a paramedic, which is closer to an AEMT/EMT-I in terms of scope of practice).

Sure, an Intermediate type provider would be an acceptable compromise.

The issue being that our Intermediates/AEMTs still do not gain much knowledge in terms of assessment. Much of the developed world staffs their ambulances with a provider that has the scope of an AEMT/Intermediate. But their courses are so much more in depth, and actually give the provider knowledge to determine how sick the patient is and whether they need additional help.

I'm sure there are intermediates in this country that can do that. But not most of them, as one needs only to look at the course curriculum and timeframe to determine that it will not be sufficient.

I don't deny that most patients just a need a ride. Most patients will "survive" a BLS transport. But we can certainly do better than "survive" and we're going to have to if EMS is going to have any sort of future.