Basics before Advanced

[Ridryder911]

I continue to read and hear the old saying.... "remember basics before advanced... one, should know the basics before ever attempting advance....."

If this was really the case, one should know the basics of anatomy and physiology and have a complete understanding of shock physiology as well before being taught treatment of shock therapy(i.e. IV therapy, intubation, etc).

The same as the full understanding of blood pressures and what causes them as well the meaning of differentials, not just bits and peices that is now taught.

Since these items are not really "advanced" rather are the basics; and one should know the "basics" before allowing or being taught therapy for problems.

As a medic or EMT, do you find most medics have an understanding of glycolysis and understanding of V02 & MR02 and multiple organ shutdowns (MODS)?

It appears, we want to emphasize the basics of everything, yet when it comes down to really understanding the "basics" most have very little or no knowledgeof such.

R/r 911

 

[TKO]

Isn't that really what you are saying too? Know the basics before you try the advanced = basics before advanced?

I agree that nobody should be attempting to perform a skill that they do not fully understand. Just because one manual says to hyperventilate a cerebral herniation doesn't mean a provider should be doing 24-30 RR/min with a BVM. If that provider doesn't realize that they can increase the cerebral ischemia and is just doing as they are told, then what makes them any more useful to the pt than dumb luck?

That is the dance of the EMT and the paramedic. EMTs should be paired with a medic, and performing under the direction of the paramedic. And the paramedic should know very well what it is he/she is doing.


Out of curiosity, what is the education of a paramedic in the US? Here in Canada, ACPs are *almost* the equivalent of an RN. If the College of Nursing hadn't welched on their end of the bargain, ACPs would have been able to challenge for an RN degree. And that wasn't for lack of knowledge, but moreover because of politics.

PCPs do 500 hours of course time, or the equivalent of 1.25 years of fulltime university education. ACPs go to school 7 hours/day for just over a year. That's pretty close to the 4 year university RN degree (minus all the practicums for both professions).

 

[VentMedic]

Since these items are not really "advanced" rather are the basics; and one should know the "basics" before allowing or being taught therapy for problems.

As a medic or EMT, do you find most medics have an understanding of glycolysis and understanding of V02 & MR02 and multiple organ shutdowns (MODS)?

It appears, we want to emphasize the basics of everything, yet when it comes down to really understanding the "basics" most have very little or no knowledgeof such.

R/r 911

So, essentially what we perceive to be advanced is really less than basic level by many other standards in the healthcare profession.

 

[Rattletrap]

I always start with the simple basics / "old horse medicine" first. It is amazing what can be fixed with simple Oxygen and coached breathing " take nice slow deep breaths".

 

[Summit]

I continue to read and hear the old saying.... "remember basics before advanced... one, should know the basics before ever attempting advance....."

If this was really the case, one should know the basics of anatomy and physiology and have a complete understanding of shock physiology as well before being taught treatment of shock therapy(i.e. IV therapy, intubation, etc).

The same as the full understanding of blood pressures and what causes them as well the meaning of differentials, not just bits and peices that is now taught.

Since these items are not really "advanced" rather are the basics; and one should know the "basics" before allowing or being taught therapy for problems.

R/r 911

I AGREE!!!

 

[Guardian]

So, essentially what we perceive to be advanced is really less than basic level by many other standards in the healthcare profession.

I don't think so. I'm sure rid will correct me if I'm wrong but, I think he meant that people are always harping on the "basics" but really have no concept of what the "basics" really are. EMT-basics don't have a good basic medical foundation of knowledge. So it is strange to hear them constantly say basics before advanced care, and I wish they would follow their own advice.

I have yet to see a paramedic intubate a breathing pt without respiratory distress, who is AAO*3. I've yet to see a paramedic forget to backboard someone (although they might choose not to). I have yet to see a paramedic worry about starting a 22g in the hand while their pt has an active femoral bleed spraying blood everywhere. Can someone please tell me where the paramedics are neglecting to perform bls care. I don't see it. Bls before als is common sense and doesn't need to said over and over. I assure you, you can't pass a paramedic exam (practical or written) unless you do bls before als. It's ingrained into paramedic students from day one. For example, when paramedics practice at airway stations, we must start off with scene safety, bsi, abc's, etc. If someone goes and picks up the laryngoscope without saying a word, the instructor/evaluator will immediately say "stop, do it again and this time do it right." It's like this for every topic, practical station, etc. There really is no bls and als, only a list of steps that emt-basics stop at around step 5 and paramedics are expected to continue to step 10. More often than not, it seems that emt-basics use this phrase as a justification for existence. I think it's unnecessary, dumb, and as some would say "played out."

 

[VentMedic]

Thank you GUARDIAN.
You've supported my statement very well since I was referring to Paramedics. I'm sure Rid will offer a further explanation of his post later.

EMT-Bs know what they know and make the best use of their basics.

Paramedics sometimes don't know what they don't know.

 

[Guardian]

well, ok. I see what your saying and I pretty much agree. I guess it's just a matter of focus between emt and paramedic or ems and other healthcare professions. I do think we have to be careful not to bog down ems with info they will never use so that we can focus in greater detail on info we will use to save lives. Where do we draw the line?...that's a complicated issue which should be studied by academics with input from other healthcare providers as well as a large number of the best ems leaders in the country...definitely not cut-and-dry. I would love however, to learn what specific additional information you would add to the mandatory emt and/or paramedic curriculum. My personal opinion (as biased as it may be) is that the critical care paramedic's knowledge, while lacking, is relatively far better than the emt-b,I,etc. and so I would flip the emt-b and paramedic in your last two sentences.


ps, I love that rumsfeld quote.

 

[VentMedic]

The Unknown
As we know,
There are known knowns.
There are things we know we know.
We also know
There are known unknowns.
That is to say
We know there are some things
We do not know.
But there are also unknown unknowns,
The ones we don't know
We don't know.

—Feb. 12, 2002, Department of Defense news briefing

 

[Ridryder911]

Great dialogue. Yes, I did have more than one meaning and intent. As I had thought, the replies are from posters that have a true understanding of what the true "basics" are.

I find it ironic that many acclaim to state.... 'basic before advanced" and one cannot be a good at advanced level, without being a good basic" without realizing what the "basics" really are.

EMS is one of the few medical professions that teaches bass ackwards. We allow one to intubate, perform intravenous therapy, and even administer medications, without having the "basic knowledge". In fact, one that usually really knows and understands the "basics" are really considered to be at an upper level of being advanced... makes sense huh? Again, in comparison of the medical community, it is backwards and odd, then we wonder why.. "they don't understand and appreciate us".

Worse, it evens starts before any introduction of EMT training. One has to have the "basics" of reading and writing, to be able to understand those so called "basics" that are needed to build the essential foundation to provide adequate health care. Many EMT courses may require reading and general education tests such as HOBET, Briggs, etc for entrance but very few have standards that eliminate or restrict candidates.

I find it ironic, there are many that want to state.."basic before advance".. then yet, they themselves may not even understand or have the basics covered. It is hard to compare, when one has nothing to compare it to.

TKO, unfortunately EMS in the U.S. is very fragmented and antiquated. One can go from the start to finish (Basic to Paramedic) in less than four months. Albeit, many do not and as well many may pursue much longer obtaining an education, the general criteria is the same.

My points is multiple and I encourage discussion, especially from those that always emphasize the statement of .. basics before advance..

We all are in agreement, every one should have the "basics" before advance. As I agree, and stated it is definitely needed as a foundation to build upon before proceeding upwards to any advanced levels. This means one should have a thorough knowledge of the basics of the workings and parts of the body, way before procedures such as intubation, intravenous therapy, and of administering of any solutes & medications.

Since we are all in agreement of that.. Why do we allow and promote not teaching the basics?.. and much more than that, since everyone appears to be in agreement again, .."basics before advance".. Why do we promote such certifications and levels that does not include those much needed "basics"?

So yes, one does need to know the osmolality and potassium shift, as well as respiratory drives and physiology of why the differences in ventilatory systems, before any thought of altering or even repairing any of those applied systems. The old cliche.. one cannot fix, that they do not what is broke" could not be more true. One has to know normal before abnormal.

So I open up for discussion and debate, especially those that acclaim .."basics before advance" the following:

Basics are never not really taught the " basics" at all, even then I would predict even that majority of Paramedics are not taught them as well.

It is hard or even hypocritical to acclaim such statements as "basics before advance", if one does not really have the knowledge of the basics themselves.

The EMS system has to evaluate the current education and training systems. It is appearantly it is not working, and continues to fail. Could this possibly be related to that we are not following proven methodologies from other medical professions, that have been around a lot longer than ours?

That in providing care to patients, there is really no basic nor advance levels, rather a beginning and continuation, then finally outcome of the patient.


Discussions ?
R/r 911

 

[VentMedic]

This means one should have a thorough knowledge of the basics of the workings and parts of the body, way before procedures such as intubation, intravenous therapy, and of administering of any solutes & medications.

Since we are all in agreement of that.. Why do we allow and promote not teaching the basics?.. and much more than that, since everyone appears to be in agreement again, .."basics before advance".. Why do we promote such certifications and levels that does not include those much needed "basics"?

Dictionary definition of Skill;
a. Proficiency, facility, or dexterity that is acquired or developed through training or experience.
b. An art, trade, or technique, particularly one requiring use of the hands or body.
c. A developed talent or ability

Yes, skills are important. It is what we base our EMS certifications on. Look up almost any state and they will give you a list of skills.

Yet, how to actually become skilled is not clearly defined. Is it a video, manikin, cadaver, or the living? How many repetitions? See one, do one, teach one?

What are the qualifications of the person teaching the skills? Are they skilled? Who judges proficiency when a manikin is used?

Proficiency; The state of being able to do something very well.

Will the skill be reproducible on the living enough to be proficient?

What is "ride time"? Do students pick the busiest stations? Is seeing the same as doing? What makes for good ride time? Who determines quality ride time? Is it a trauma or medical call? How many calls?

Why aren't the skills taught the same? Who says this way is better than that way? Why are there more skills in that state than this state.

Going purely by definition, is it possible for someone of a lower certification to be more proficient and skilled than a higher certification or licensure? They could have performed the skill more times. They could have natural talent or be a quick learner of a skill. What else would there be to set them apart with that skill? Did they watch the same video? Practice on the same manikin?

Of course, to make up for deficiency in proficiency, we get better equipment. Or, so says the sales pitch from the salesperson. We can put a tube into anyone and never miss an IV.

I was looking at some of the different certifications in a few states.

Example:
Washington: First Responder, EMT-Basic, IV Technician, Airway Technician, IV/AW Technician, ILS Technician, ILS/Airway Technician, Paramedic.

The EMERGENCY MEDICAL SERVICES THE NATIONAL EMS SCOPE OF PRACTICE MODEL, which Rid mentioned in another post, points out that there are 44 different certifications and 39 different licensure levels between EMT and Paramedic in the U.S.

http://www.jems.com/data/pdf/SOPFinal4.0.pdf

Education? Basics?

Where to start?

Wouldn't it be easier if we just make up another certification or licensure and say this one is the right one THIS time? Wouldn't that be as practical as the patch work of skills certifications we have going on now?

 

[Glorified]

The only solution to this dilemma would be to make it nationally mandatory for all EMS personnel to be associate degree paramedics and the rest of EMS are first responders. But until that happens, you are going to have to endure all of us annoying basics, saying "bls before als."

 

[Ridryder911]

I think Vent you make some very valid and important points. Educators and EMS officials are quite aware that the ability of performing skills proficiently and having the associated knowledge is two different things.

The skills of the Basic EMT is considered very simplistic in the terms of hierarchy of skill level and over all rated very easy to repeat and perform with repetitious practice. However; we need to increase the education level, not just to have the basic EMT to be able to perform tasks. In simplistic terms skills are no value, without knowledge behind them. Skills can be improved and the skills of the EMT those can be mastered with clinical exposure.

As the level of practice increases with the difficulty and intensity of the skill level, many EMS educators and state officials much rather develop multiple levels than to face the task and do it right the first time. In the typical EMS fashion, the old analogy..." placing a band-aid on a arterial bleed"....and then try to "fix" it as we go. We much rather for some reason do things half ***.

Unfortunately, the questions you ask are not always able to be answered because most of the education is generally set in a "training" environment and most are never reviewed to improve. Ask most EMS educators what teaching model(s) they are using, or if they even know what critical thinking skills are, and see the response.

For as what validation can be used to assure proficiency, this is why Quality Improvement is so essential. The reason that most states and NREMT asks on re-certification of proficiency level, although I am sure it is checked off by habit instead of being truly reviewed.

I agree there is discrepancy in clinicals. That is why National Scope of training and practice is essential. Like your RT and as well as other medical models of education, objectives should be required. In lieu of clinical hours, contacts and requirement of clinical objectives should be set and used. This would prevent those "coffee clinicals" and clinical time with most action was playing a video game. In the original clinical agreement of the rough draft of the National Scope, clinical exposures required certain types of calls and medical conditions. I agree, a student should not be released until they have treated certain medical conditions. For example cardiac arrest, chest pains, trauma patients, high risk O.B.'s etc.

Many may describe one could not be guaranteed to have exposure. I argue that if the clinical site was at a metro or progressive center, the chances would be increased. Yes, this may mean travel time, but like residency and even other medical careers, that is again the represents the dedication and sincerity of the student to be able to obtain exposures

So with at least 83 multiple levels, how is the medical community supposedly take our profession seriously? When ever there is an area that is more difficult ... develop another EMT level, of course this is always in comparison to the highest level being the Paramedic... sorta....kinda... almost.. not quite. Pull out the band-aid.

When one investigates on the amount of money is spent developing levels (including tests, studies, curriculum's, etc) and instead of providing grants, tuition wavers.. many Basic EMT's could had been sponsored through the entire Paramedic course.

So how do we improve on such... support and make recommendations on the National Scope, support Advocates of EMS, discuss the education and lack of to you State EMS Director and Directing Board, become active in local, state, and national professional organizations.

Glorified you are right I will have to tolerate, but I will retaliate with forwarding back to this post every time I read Basics before Advanced. Hopefully, we can educate the Basics what really basics are and not a cliche of basic before Advanced really is.

R/r 911

 

[VentMedic]

Besides state licensing websites, there are many other sources of information. Although, this too is getting fragmented in focus by different agencies, each with their own issues instead of a true national organization to lobby for legislation. Of course this too will be difficult to get an organized representation of all of the certified and licensed EMS people, each also with their own issues.

Many do not know about the different pieces of legislation that are being or have been considered. Due to this lack of a general interest of the masses, special interest groups are able to push legislation through without being noticed. Many times it is specifically for their gain and not for the greater good of EMS.

National Conference of State Legislatures
http://www.ncsl.org/programs/health/ems.htm

http://www.ncsl.org/index.htm?tabsel=issues


The National Association of State EMS Officials
http://www.nasemsd.org/

National EMS Education Standards
http://www.nemsed.org/

These are just a few links that provide some valuable information about this profession.

 

[eggshen]

This is a tough one for me. I think one needs a broad didactic base but at the end of the day what do we do? We take people to the hospital. Too many these days seem to be addicted to the technical imparitave. If you can get it to your hands please do so...otherwise stow it, I could care less whether or not you are going to med school when you grow up.

Egg

 

[RichmondMedik]

This is a tough one for me. I think one needs a broad didactic base but at the end of the day what do we do? We take people to the hospital. Too many these days seem to be addicted to the technical imparitave. If you can get it to your hands please do so...otherwise stow it, I could care less whether or not you are going to med school when you grow up.

Egg

Try telling a Med control doc that " We take people to the hospital" and I bet you would no longer get orders or respect from them -- My old Med control doc would stress "You start treating patients in the field" and if we were unsure he would point us in the direction to get the education we needed to accomplish treating the patient correctly -

 

[MRE]

Not sure if this is completely appropreate for this thread (only had time to skim it quickly)

I am in the 4th week of Basic training and my instructor was complaining recently about the way the class has been dumbed down over the years. He said that the current Basic curriculum trains us to be assessment based EMT's as opposed to the old one which taught students to be diagnostic EMT's. He said he will be teaching our course so that we are actually trained as both.

From what I have seen so far, he has been using a bit more medical terminology than the Brady book we are using, and we have discussed some underlying causes of particular signs and symptoms that are not mentioned in the book (so far at least). One example of this is "spontaneous pnumothorax" being a problem encountered mostly with tall, thin white males.

Can anyone tell me if this is normal for a Basic course (we have only covered material up to trauma assessment so far) or if my instructor is giving us anything more? Also, please comment on the assessment vs diagnostic based EMT.

Thanks,
-Blake

 

[SMC]

My thoughts

Hello my EMS family ! New to forums.....

Basics before advanced is a popular topic these days ! And, I'm sure I don't know lots of things including...

As a medic or EMT, do you find most medics have an understanding of glycolysis and understanding of V02 & MR02 and multiple organ shutdowns (MODS)?

But look at EMS training requirements. In the state of Texas more training hours are required to become a cosmetologists than a NREMT Paramedic.

If we want our field to have an understanding about these things, we need to look at the requirements for EMS. I don't think it's our fault we don't know.

And, now I'm going to get a bad rep in here lol.

Why do I need to understand VO2 ? I see my patient for a short periods of time. I have my ETCO2 and my SPO2 and I will oxygenate my patient if needed during my short treatment time. The Dr. and the RN's at the hospital are trained for more long term treatment. The overwhelming majority of the EMS professionals in the field are not RN/paramedics. It's good you know and understand those things, but the majority of us don't and I don't think we need to.

I'm going to enjoy discussions in this forum I can tell.

Little bit about me.

I've been a paramedic for about a year now. I'm a Call Of Duty UO PC Gamer. RCA are fun. Like I said I've got tons to learn ! And I will continue to learn and educate my self on the ever changing EMS field. I like to keep things very simple in this complicated job.

SMC. EMT-P Sgt US. Marines OIF II vet. C.Ph.T (pharmacy Tech) 10 years. lol that job helped me tons with patient home medications

 

[Guardian]

This is a tough one for me. I think one needs a broad didactic base but at the end of the day what do we do? We take people to the hospital. Too many these days seem to be addicted to the technical imparitave. If you can get it to your hands please do so...otherwise stow it, I could care less whether or not you are going to med school when you grow up.

Egg

Why do you think ems was invented? We already had people to drive pts to the hospital. We were supposed to be more than that. I guess it's a matter of perspective. What seems like too much technical imperative to you is just scratching the surface to me. I don't want us to become doctors; right now, I'm just trying to get back to the level of understanding we had 30 years ago.

 

[VentMedic]

I'm just trying to get back to the level of understanding we had 30 years ago.

That is so true.

The phrase "physcian extender" was coined for us almost 40 years ago. At that time our skills and knowledge were unique to us and physicians. Unfortunately it is used loosely today and holds no legal bearing. PAs and NPs are two of the legal physician extenders. Their extensive education and clinical hours give them that privilege.

The skills we possess are no longer unique to just the Paramedic. Many other healthcare professions also practice advanced skills along with protocols and standing orders. For many, their education has to meet certain standards with many hours of clinicals before they are granted these privileges. They are also required to maintain competencies that is not heard of in many EMS agencies.

When viewed on a national level as a whole we are now skilled "technicians". Our varied certifications and licensures make it difficult to give credit to those in the profession who have truly put forth educational and skills betterment.

In many situations:
"You are only as strong as your weakest link."