Different angle: why basic level technicians?

[Ghostnineone]

It seems like requiring paras to be PA's or MD's is too much to me...because while there are some that will work as an EMT on the side, how many will choose to work as an EMT full time that might not get payed much vs PA or MD that gets payed more? Especially when they could just work in the ED. I don't think I'd want to go to med or PA school and do an internship and residency and have 100k in debt if i just want to be a paramedic.

The clinical knowledge would be helpful, but how much of it will they use on the scene or in the back of an ambulance? Would you do a chest tube insertion in an ambulance? What about a thoracotomy? Central lines? It seems like there would be a lot of "hospital only" skills that they would have to learn but never use in EMS.

Am I not understanding something? :/

 

[DPM]

I have to disagree with 'thegreypilgrim' on this. Every single call requires BLS. You can't argue that. However you will find that not every call requires ALS and a tiered system is absolutely necessary. Removing EMT-B and requiring a degree isn't necessary for the type of care and the skill set that your basic level needs.

EMT- Basics have a basic level of training but they are still a valuable resource. There is more to their scope than Back boards an O2, and the most commonly used interventions listed in your 'Basic Medic' scope are skills that they can perform.

I do like your Advanced Paramedic idea though. In the UK and Australia and a few other EU countries there is a very similar system in place, Paramedic Practitioners (not to be confused with critical care). They have an expanded scope but work as more of a 'traveling primary care'. Research has shown that a large proportion of ER visits are for things that can and should be seen at your GP or Dr's office. The Paramedic Practitioner will make a home visit with the aim of diagnosing and treating on scene without having to take the PT to hospital, thus freeing up ER resources and saving money in the long run.

And again, I like your last point about separating Fire and EMS. With Fire departments already providing ALS and BLS we already have government funded EMS, people just don't realize it. If we want FD to proved EMS services then we need to go all the way and have all EMS and transport provided by Fire with their own ambulances. AMR / Rural Metro / Paramedics Plus have all shown that EMS can be profitable, so I don't see how this would be a problem financially for a FD to step in.

Or we can go the other way to a 3rd service, an Ambulance service. They will have the SOLE responsibility of providing EMS and transport, and would be managed and funded in a way comparable to local Police and Fire Departments.

Being stuck in the no man's land of half private and half public isn't the most effective and efficient use of our medical resources, and I feel that removing private EMS from the equation is the solution.

 

[Tigger]

I have to disagree with 'thegreypilgrim' on this. Every single call requires BLS. You can't argue that. However you will find that not every call requires ALS and a tiered system is absolutely necessary. Removing EMT-B and requiring a degree isn't necessary for the type of care and the skill set that your basic level needs.

EMT- Basics have a basic level of training but they are still a valuable resource. There is more to their scope than Back boards an O2, and the most commonly used interventions listed in your 'Basic Medic' scope are skills that they can perform.

I do like your Advanced Paramedic idea though. In the UK and Australia and a few other EU countries there is a very similar system in place, Paramedic Practitioners (not to be confused with critical care). They have an expanded scope but work as more of a 'traveling primary care'. Research has shown that a large proportion of ER visits are for things that can and should be seen at your GP or Dr's office. The Paramedic Practitioner will make a home visit with the aim of diagnosing and treating on scene without having to take the PT to hospital, thus freeing up ER resources and saving money in the long run.

And again, I like your last point about separating Fire and EMS. With Fire departments already providing ALS and BLS we already have government funded EMS, people just don't realize it. If we want FD to proved EMS services then we need to go all the way and have all EMS and transport provided by Fire with their own ambulances. AMR / Rural Metro / Paramedics Plus have all shown that EMS can be profitable, so I don't see how this would be a problem financially for a FD to step in.

Or we can go the other way to a 3rd service, an Ambulance service. They will have the SOLE responsibility of providing EMS and transport, and would be managed and funded in a way comparable to local Police and Fire Departments.

Being stuck in the no man's land of half private and half public isn't the most effective and efficient use of our medical resources, and I feel that removing private EMS from the equation is the solution.

Yet much of the developed world operates their frontline ambulances in a manner like thegreypilgrim has described. There is no reason to differentiate between ALS and BLS, it's all medicine.

Not every call requires advanced interventions or education, but there is no reason why someone with those qualifications cannot take such a call. Our BLS providers are capable of transporting most patients without having their condition decrease in a meaningful way, but that does not make it the best practice. An extremity fracture could just be a BLS call; splint, ice, and transport. Or we could throw a better educated provider into the mix who can provide pain relief. Either way the patient is not going to die on the way to the hospital, but with a higher level provider the patient is not going to be suffering, and that is almost as important as the whole "EMS saves lives thing," if not more so.

 

[JPINFV]

And before anyone calls me any education, I have my degree, and have completed all by one requirement to get into med school (MCATs). Organic Chem was a :censored::censored::censored::censored::censored:, esp when taking it and Bio 2 at the same time, and working 60 hour weeks in two busy EMS systems.

Anyone who's completed a degree in biology has achieved that. Actually, the pre-reqs for med school aren't exactly difficult. Finishing them with grades that make the student competitive is a different question altogether, and why the US med school admissions rate is something like 50%.

 

[JPINFV]

Consider a parallel: get rid of nurses and staff hospitals with only MD's. Aren't there some advantages to tiered coverage ?

Nursing and medicine are two different things. Heck, I've completed my first rotation and I still haven't started an IV. Physicians are educated in the diagnosis and treating disease and health maintenance. Nurses are educated in implementing the physician's treatment plan and the personal side of patient care (feeding, bathing, turning, etc). Nurses aren't physician + ___ and physicians aren't nurses + ____. Both are integral to providing good patient care even if cleaning up poop isn't as sexy as ordering Tylenol PRN for fever.

However a paramedic is an EMT + _____, which is why an EMT can be replaced on an ambulance with a paramedic, but a physician can't replace a nurse in a hospital.

 

[JPINFV]

I have to disagree with 'thegreypilgrim' on this. Every single call requires BLS. You can't argue that. However you will find that not every call requires ALS and a tiered system is absolutely necessary. Removing EMT-B and requiring a degree isn't necessary for the type of care and the skill set that your basic level needs.

The only way that it can be argued that every call needs at least an EMT ("BLS") is if the assumption is that every call needs to be transpoted and an EMT is the lowest level allowed to staff an ambulance. If a patient could have gone by a taxi and be none the worst than the patient didn't need BLS.

EMT- Basics have a basic level of training but they are still a valuable resource. There is more to their scope than Back boards an O2, and the most commonly used interventions listed in your 'Basic Medic' scope are skills that they can perform.

Such as? The vast majority of patients who receive a backboard or supplemental oxygen don't need them, and the handful of other interventions (e.g. ASA for ACS or oral glucose) are such that the patient should have additional treatment options available immediately anyways. The vast majority of trauma interventions (splinting, bleeding control, etc) are taught to boy scouts, which doesn't exactly make them very special in terms of interventions.

 

[DPM]

I feel like I didn't get my point across well. I wasn't saying that all calls require BLS. Your taxi analogy is spot on, some cases don't really require any treatment. Others require a lot of specialized care, and there is everything in between. I'm just saying that I don't think we need to 'upgrade' EMT-B when our 911 ALS services already have a Paramedic on board. At a time where we are trying to reduce EMS costs, can we afford the extra pay a more advanced basic level would require? Especially when we've all pointed out that a lot of the time this extra training isn't needed, and in cases where it would be, there is already someone else there who has a higher level.

Tigger, I disagree with you on your ideas of how the rest of the world operates. One example, the London Ambulance service, has 4 Levels of EMT, 4 of Student and 2 of Paramedic. They have normal ALS ambulances, BLS PT transport, ILS Bikes, Paramedic RFVs and they also have the capability to send forward ER Drs using HEMS or a FRV. I lived for a while in Germany and they were similar.

I'm not saying 'lets just use BLS because it'll probably be ok', and I do agree with you that having someone with the training to deliver a higher level of care is always better. I just feel that if we have our Paramedics and an existing intermediate scope in place, do our EMT-Bs need to be some kind of Intermediate-lite?

The point of what I was trying to say was that, in my opinion, the level of training that our basic level providers have is adequate and suitable for the role that they perform.

 

[Tigger]

I feel like I didn't get my point across well. I wasn't saying that all calls require BLS. Your taxi analogy is spot on, some cases don't really require any treatment. Others require a lot of specialized care, and there is everything in between. I'm just saying that I don't think we need to 'upgrade' EMT-B when our 911 ALS services already have a Paramedic on board. At a time where we are trying to reduce EMS costs, can we afford the extra pay a more advanced basic level would require? Especially when we've all pointed out that a lot of the time this extra training isn't needed, and in cases where it would be, there is already someone else there who has a higher level.

Tigger, I disagree with you on your ideas of how the rest of the world operates. One example, the London Ambulance service, has 4 Levels of EMT, 4 of Student and 2 of Paramedic. They have normal ALS ambulances, BLS PT transport, ILS Bikes, Paramedic RFVs and they also have the capability to send forward ER Drs using HEMS or a FRV. I lived for a while in Germany and they were similar.

I'm not saying 'lets just use BLS because it'll probably be ok', and I do agree with you that having someone with the training to deliver a higher level of care is always better. I just feel that if we have our Paramedics and an existing intermediate scope in place, do our EMT-Bs need to be some kind of Intermediate-lite?

The point of what I was trying to say was that, in my opinion, the level of training that our basic level providers have is adequate and suitable for the role that they perform.

Lets leave IFT out of all of this, there is really no reason it should be included in EMS beyond the fact stretcher transport is common between the two. London's IFT ambulances aren't responding to 911 calls (ever) so that's kind of a moot point. Their 911 ambulances (or whatever number, 111?) are all some sort of ALS. In much of this country, that is not the case. It might be where you are, but I can assure you that there are many places that send 911 BLS ambulances only. That's where there is a problem, our patients deserve more than BLS care during their emergency. If it's a medic/basic truck that's one thing, but a straight BLS truck doing 911 isn't exactly 21st century medicine.

 

[DPM]

Lets leave IFT out of all of this, there is really no reason it should be included in EMS beyond the fact stretcher transport is common between the two. London's IFT ambulances aren't responding to 911 calls (ever) so that's kind of a moot point. Their 911 ambulances (or whatever number, 111?) are all some sort of ALS. In much of this country, that is not the case. It might be where you are, but I can assure you that there are many places that send 911 BLS ambulances only. That's where there is a problem, our patients deserve more than BLS care during their emergency. If it's a medic/basic truck that's one thing, but a straight BLS truck doing 911 isn't exactly 21st century medicine.

I'm with you 100% on that point. My suggestion would be instead of improving / upgrading the existing EMT-B scope, we should properly implement the existing Intermediate scope. So in these (I'm assuming rural) communities there is an ability to provide better care while keeping costs down (EMT-B gets EMT-B pay, Intermediate gets Intermediate pay etc).

Of course I'd rather all 911 had a Paramedic on board, I just don't think that both people on the ambulance require advanced training.

 

[Ghostnineone]

I sorta don't understand having 4 levels of EMS thing...if its a basic/para, then where do I and CC fit in? And why do you need I and CC if there is a paramedic on board anyways? I guess if it was a really bad PT then having someone with I or CC could help. What would happen if there was only ALS providers on every rig? They can all do BLS. There just seems to be way, way too many ways to do things...

 

[DPM]

I sorta don't understand having 4 levels of EMS thing...if its a basic/para, then where do I and CC fit in? And why do you need I and CC if there is a paramedic on board anyways? I guess if it was a really bad PT then having someone with I or CC could help. What would happen if there was only ALS providers on every rig? They can all do BLS. There just seems to be way, way too many ways to do things...

The issue is that some areas cannot afford to provide Paramedics / ALS ambulances. Ideally, all 911 would have at least one Paramedic on board but unfortunately that isn't the case. So having a tiered system should make a higher level care available without the Paramedic price tag.

 

[thegreypilgrim]

The issue is that some areas cannot afford to provide Paramedics / ALS ambulances. Ideally, all 911 would have at least one Paramedic on board but unfortunately that isn't the case. So having a tiered system should make a higher level care available without the Paramedic price tag.

This is why you fund at state-level. As long as local communities have to pay for EMS you're going to have this disparity in resource availability.

 

[thegreypilgrim]

I have to disagree with 'thegreypilgrim' on this. Every single call requires BLS. You can't argue that. However you will find that not every call requires ALS and a tiered system is absolutely necessary. Removing EMT-B and requiring a degree isn't necessary for the type of care and the skill set that your basic level needs.

You can't have a tiered system that consists of EMT-Bs and Paramedics. To be blunt, EMT's have no real utility other than being sort of like "assistants" on scene as most areas their scope literally is O2, backboard, band-aids and for good reason. It's not a solution to just graft extra skills on a 120 hour training background. As it is "BLS" offers very little to the majority of patients that access 911 other than just transport which defeats the purpose of tiered-response. What is needed is a professional-level educated provider who can utilize some degree of clinical judgment and perhaps not transport every patient they see.

Furthermore, they should be operating without on-line medical control since that whole practice wastes time and costs hospitals hundreds of thousands of dollars every year to maintain.

 

[mycrofft]

Nursing and medicine are two different things. Heck, I've completed my first rotation and I still haven't started an IV. Physicians are educated in the diagnosis and treating disease and health maintenance. Nurses are educated in implementing the physician's treatment plan and the personal side of patient care (feeding, bathing, turning, etc). Nurses aren't physician + ___ and physicians aren't nurses + ____. Both are integral to providing good patient care even if cleaning up poop isn't as sexy as ordering Tylenol PRN for fever.

However a paramedic is an EMT + _____, which is why an EMT can be replaced on an ambulance with a paramedic, but a physician can't replace a nurse in a hospital.

So you would teach and require the MD's to do that sort of care. It is real healing, not just throwing knowledge out as orders and watching for a result. The parallel I was trying to raise and others have to a degree is that as we add tiers we delete duties from those who are "on the top"; however, what if we took thirty embryonic nurses, thirty embryonic doctors, and thirty embryonic PA's, and instead made them all generalists, doing EVERYTHING? (Same for ALS versus BLS).

 

[mycrofft]

The issue is that some areas cannot afford to provide Paramedics / ALS ambulances. Ideally, all 911 would have at least one Paramedic on board but unfortunately that isn't the case. So having a tiered system should make a higher level care available without the Paramedic price tag.

Some areas cannot attract medical providers, much less afford them.

 

[mycrofft]

You can't have a tiered system that consists of EMT-Bs and Paramedics. To be blunt, EMT's have no real utility other than being sort of like "assistants" on scene as most areas their scope literally is O2, backboard, band-aids and for good reason. It's not a solution to just graft extra skills on a 120 hour training background. As it is "BLS" offers very little to the majority of patients that access 911 other than just transport which defeats the purpose of tiered-response. What is needed is a professional-level educated provider who can utilize some degree of clinical judgment and perhaps not transport every patient they see.

Furthermore, they should be operating without on-line medical control since that whole practice wastes time and costs hospitals hundreds of thousands of dollars every year to maintain.

Haven't we established elsewhere/when that the majority of 911 calls DON'T require advanced life support? And many don't really require BLS either?
But I am sympathetic to your reconsideration of tiered responses.

Here's a rhetorical question: why is it (or IS it?) "beneath" paramedics to be called and to provide basic treatment? To revisit an earlier post of mine, if everyone was a paramedic, the wage would down, so it wold be affordable. But could enough people, or enough in a given region, pass the training to become one?

 

[mycrofft]

This is why you fund at state-level. As long as local communities have to pay for EMS you're going to have this disparity in resource availability.

I think maybe national too, as they do or did) for Indian reservation clinics and GS positions at such places as Johnson Island, Antarctica, etc.

Hey, use the military, especially National Guard and Reserves.

But definitely, some areas deserve better than they can afford.

 

[JPINFV]

So you would teach and require the MD's to do that sort of care. It is real healing, not just throwing knowledge out as orders and watching for a result. The parallel I was trying to raise and others have to a degree is that as we add tiers we delete duties from those who are "on the top"; however, what if we took thirty embryonic nurses, thirty embryonic doctors, and thirty embryonic PA's, and instead made them all generalists, doing EVERYTHING? (Same for ALS versus BLS).

However, the problem is that for EMS we're comparing the same professional field, while for medicine vs nursing we're comparing different professional fields. However I will argue that when it comes to inpatient medical care, there is a large bit of throwing out orders and waiting for results. Obviously, the physician needs to understand the practical ramifications of his orders (i.e. vitals Q4 hours overnight...). Otherwise you're going to expect the admitting physician to be an expert in medicine, nursing PT, dietary, radiology, and numerous other fields. That's not really the same as having different tiers within the same profession.

The closest thing when it comes to tiers would be specialties to subspecialties. A cardiology and a pulmonologist should be able to both manage regular inpatients since both are specialized in internal medicine prior to subspecializing in pulmonology or cardiology. Thus a pulmonologist or cardiologist is an internal med physician + _____, just like a paramedic is an EMT + _____ under the current system.

 

[thegreypilgrim]

Haven't we established elsewhere/when that the majority of 911 calls DON'T require advanced life support? And many don't really require BLS either?
But I am sympathetic to your reconsideration of tiered responses.

We need to abandon the whole dichotomy between "BLS" and "ALS". It's no longer a useful concept. So, while it's true that very few 911 patients actually require "life saving care" however you wish to define it, it remains true that they are going to require some level of medical intervention. That's why we need a provider who can fill that role whilst simultaneously being able to initiate resuscitative or otherwise "invasive" care. That would be the new "BLS" - an ambulance officer who can handle the majority of calls. The new "ALS" would be an intensivist who is available on retainer for those rare calls that actually do require life-saving efforts as well as being someone who can connect less acute patients with alternative resources in a systematic way.

Here's a rhetorical question: why is it (or IS it?) "beneath" paramedics to be called and to provide basic treatment? To revisit an earlier post of mine, if everyone was a paramedic, the wage would down, so it wold be affordable. But could enough people, or enough in a given region, pass the training to become one?

It isn't "beneath" them, but there needs to be an appropriate matching of resources. These "basic" patients deserve and require something more than a 120-hour glorified first aider, but then there needs to be a separate specialized provider for those complex and high-acuity cases who can deliver invasive and intensive care.

 

[thegreypilgrim]

I think maybe national too, as they do or did) for Indian reservation clinics and GS positions at such places as Johnson Island, Antarctica, etc.

Hey, use the military, especially National Guard and Reserves.

But definitely, some areas deserve better than they can afford.

National would be even better, even if it was under the same rubric of the old 1973 EMS Act.