emt-b meds

[jrm818]

. If there is a statistic out there that shows that dual paramedics have a higher success rate in terms of the outcome of treating their patients, Id like to see it and have the source cited. Ive never seen such a study, and I have looked high and low for it. I)

Well really there isn't much data (that I can find) to suggests that ALS in general has a huge impact on patient outcome at all. The majority, if not all, of the studies that have been done have methodological problems, and the data seems to be pretty conflicting and ambiguous. A few studies have sorta suggested ALS can have some imporvement in cardiac arrest (maybe), and maybe some impact on trauma, but overall the impact of ALS is far from indesputable. There are just as many (if not more) studies that have suggested no difference between ALS and BLS systems. The only consistancy among the studies that I can find is that the data is impeachable in them all.

So what's the deal? Am I missing some stellar major study that once and for all established that an ALS system is far far superior to a BLS sytem, and worth any cost?

 

[DisasterMedTech]

No, I dont think your missing some unimpeachable study that shows that patients are more likely to arrive at hospital "alive and viable" more often or with greater consistency simply because there is an ALS provider on board. Ive dont literature searches in JEMS, the Journal of the American Medical Association and non-US sources like the Lancet. The statistics just arent there. As you say, perhaps in cardiac situations where cardio-verting is necessary we can say that there is a great advantage to having someone on the crew who can push drugs. As I say, though, I would also be interested to see statistics surrounding the number of patients whose condition is worsened due actions of ALS providers and the same statistics for worsened condition for BLS providers. Perhaps it would be found that because of the complexity and diversity of interventions performed by ALS responders that there are more likely to be mistakes.

Also, just out of curiosity, I wonder what the ALS members of this forum think of EMT-I providers. In a move that I much disagree with, we are doing away with them slowly but surely here in Illinois. Just across the state line into Wisconsin they are still very much in use and they dont seem to have plans to eliminate them any time soon. When I worked and lived in the Southwest, I saw more of them than I do here in the Midwest. Id be interested to know what the difference in training time, etc is between EMT-Is and EMT-Ps in the various states where both are licensed. It seems to me to be a good idea to have this in between step. If I could, I would very much like to go to Intermediate before going to Paramedic, but alas, they are a dying breed where I live.

 

[Ridryder911]

EMT/I is just another excusable level not to have the real deal. Remember, all multiple levels are compared to what? The Paramedic.

Dependent on the level of Intermediate (I/99-84) It can range from a 4 week class to 9 months. Again skill levels can vary as well.

Why can't we in EMS do the right way the first time, instead of doing it half arse?

In regards to studies there are multiple studies verifying differential from ALS to BLS. The majority is in prevention and recognizing injuries and illnesses and treatment of acute care. Then in reality if one really considers the treatment of BLS, maybe just transportation would be enough?

R/r 911

 

[skyemt]

if you guys are trying to imply that there is little difference between bls and als crews, you are making the rest of us EMT-B's look very silly for no reason!

"here comes the ambulance... i really hope there are no Paramedics on board!"

you guys can't be serious...

 

[emt/ff71185]

EMT/I is just another excusable level not to have the real deal. Remember, all multiple levels are compared to what? The Paramedic.

Dependent on the level of Intermediate (I/99-84) It can range from a 4 week class to 9 months. Again skill levels can vary as well.

Why can't we in EMS do the right way the first time, instead of doing it half arse?

In regards to studies there are multiple studies verifying differential from ALS to BLS. The majority is in prevention and recognizing injuries and illnesses and treatment of acute care. Then in reality if one really considers the treatment of BLS, maybe just transportation would be enough?

R/r 911

When you say doing it half arse, are you saying that going from EMT-B to EMT-I to EMT-P is doing it half arse or are you saying that we should all just go straight to EMT-P without a good base? I have never heard of a course that takes someone with out an EMT-B license at least and makes them a paramedic. If there out there then that is fine but from everything I know you have to start as an EMT-B so it is not necessarily doing it half arse. It is just being in process to a higher license.

On your other topic... I do feel like ALS is vital to a good medical system but so is BLS because in the outlying regions, BLS is what is going to get to that patient first and keep them going until we can get ALS out to us. Everyone is needed. Obviously being a Paramedic gives you a lot more knowledge and in a perfect world it would be great if everyone that climbed into a rig was a paramedic but because that is not going to happen outside of cities why do away with the next best thing?

 

[JJR512]

EMT/I is just another excusable level not to have the real deal. Remember, all multiple levels are compared to what? The Paramedic.

Dependent on the level of Intermediate (I/99-84) It can range from a 4 week class to 9 months. Again skill levels can vary as well.

Why can't we in EMS do the right way the first time, instead of doing it half arse?

You may compare everyone else to your level (EMT-Bs don't know as much, doctors know more); I may compare everyone to my level (paramedics are better, doctors are even more better); doctors might compare everyone else to their level (paramedics are lower, basics are even more lower). We all have our knowledge and skill set, we all have our uses and our place, but to put yourself at the center of everyone else just blows my mind.

Why can't we do it right the first time? I assume from the egotistical attitude of the preceding section, I assume you mean why can't we all just be paramedics? Answers are as follows:

1. Time. Not everyone gets the idea of becoming a paramedic in time to go to paramedic school right out of high school (i.e., going to college and getting a 2- or 4-year degree as a paramedic). Later in life, it can be difficult to find the time for paramedic classes. Most of the paramedic programs in my area have a class/clinical/study load that is impossible to maintain while working a full-time job, so by the time some people decide to ditch whatever their old careers were to become a paramedic, they have responsibilities that require time put into working a full-time job.

2. Money. This ties in with the preceding answer. Not everyone can afford to switch to a part-time job so that they'll have the time to take paramedic classes. Additionally, not everyone can afford to take the classes in the first place. One community college estimates the cost of their paramedic certificate program to be $5,136, while their degree program (AAS) is estimated to cost $6,566. Five or six thousand dollars isn't a lot of money to people that have five or six thousand dollars of disposable money sitting around, but it's a heck of a lot of money to a heck of a lot of people. And not everyone can get financial aid or loans.

3. Interest. So one day, doing whatever non-health-care job he does, Joe Schmoe is suddenly going to have an idea to leave his current industry/career and become a paramedic, so he quits, goes to paramedic school for one and a half to two years, becomes a paramedic, and gets hired by his city's fire department. Actually...I don't think so. Taking classes two nights a week for half a year while keeping his regular job, so he can become an EMT-B, work one or two nights a week and maybe a weekend day or the whole weekend now and again, to get a taste for what EMS is like, sounds like a more sensible plan to me. Then Mr. Schmoe either decides that it's not really his thing and he stops doing it, or he decides that it is, he'd like to do it more and do it better, and eventually becomes a paramedic.

There are probably other reasons why we don't all "do it right the first time", but there's three I could think of quickly.

 

[Ridryder911]

Most studies that have been referred to, have been addressed multiple times and reviewed by many as tainted and bias studies. The major comparison was in regards to cost effectiveness of BLS versus ALS. Again, many that read such studies do not understand research and statistical results. Studies such as OPALS, and others have pointed out BLS in comparison appears to provide better results. Again, what many fail to read is that it is based upon BLS responding in < 8 min and have transport times within reasonable time to an appropriate center.

In reality, what can BLS really do? Oxygen, bandaging, splinting, and some some supplemental medications... that is it. Initial treatment and assessment until medical intervention can occur. We have found out that IV fluid therapy in the field setting does more harm that actually good, providing "wash out" in shock syndromes, intubations without advance training (i.e. RSI) in trauma patients has drastic lower successes (Wang), and randomly administering NTG in non-monitored and no IV access patients can be detrimental in many AMI patients.

The advantages of ALS is similar to any medical care. Prevention and treatment of illnesses. If we base our existence solely on outcome basis, we would never even attempt resuscitation efforts.

Examples of differences is primarily seen in cases such as recognizing early cardiac infarctions, cerebral hemorrhages and stroke syndromes, pain management, and again in trauma the securement of airway and treatment of respiratory complications. Advance assessment skills with diagnostic tools, and in-depth interpretation; is the key in having major difference. Being able to notify ahead for early alert for cardiac catheterization, tPA for AMI and those that meet eligibility for CVA's versus those do not meet the criteria. Treatment or abolishment of life threatening arrhythmias, treatment of upper and lower airway complications, and treatment of general medical emergencies. Obstetric emergencies and neonate advance treatment definitely has a great differential. As well, low number of studies of transport of seriously ill patients that requires specialty care from small local hospitals to tertiary hospitals.

The problem in most studies are that they usually are performed in high call volume, low protocol services, with receiving hospitals within a few minutes of EMS responses. Of course, most that work in EMS realizes that this is not where the emphasis of a progressive EMS should be. Rural areas, where treatments I described earlier are the ones that could benefit and actually have a potentially of change in outcomes. Again these are not where these studies are usually conducted. Low volume, poor statistical data, and multiple variables are the reasons they are not performed in rural setting. It would take years to obtain enough cases and data.

Many are beginning to see EMS outside the box. For EMS to survive and be beneficially funded we will have to change our profession from pre-hospital to out-of-hospital expanded care. Again, compare to our neighbors in Canada, Australia, England, etc. (This is a another subject for another thread).

BLS is part of patient care, not separation or a division, just like the so called ALS. Patient care should be in one continuum, with no separation. Only in EMS we attempt to separate the two in care.

R/r 911

 

[jrm818]

Rid i'm definatly with ya on the poor study quality. I wasn't suggesting that studies which have shown that BLS is as effective as ALS (and yea...ive read at least one study that, as i recall, endorsed a "scoop and scoot" method) are of good quality or shoudl be taken as good evidence against ALS. But I simply can't find any good quality studies which suggest that ALS is at all effective in improving either short or long term patient outcome.

I respect your years of knowledge and experience, but on a system-wide level, there has to be evidence of a benefit (and evidence of a lack of harm) before tons of money are spent on providing a specific treatment (in this case ALS). This is no different than any other medical treatment - evidence based medicine is a model i'm more than willing to defend.

Unfortunatly what i suspect is that there's not the funding to do such a study, and even if there was, good quality studies i na field like this would be extraordinarily difficult. I'm not sure what to do in that situation, as I also don't see simply assumign that more is better as a viable alternative.

 

[BossyCow]

In reality, what can BLS really do? Oxygen, bandaging, splinting, and some some supplemental medications... that is it. Initial treatment and assessment until medical intervention can occur.
R/r 911

Rid,
You left out a biggie, probably the most important role that the lowly EMT-B in the rural setting plays. We transport to the hospital. My agency covers a 52 square mile district with mountains to the south and the salt water to the north. We have a highway that runs east to west through the middle of it. This highway is often blocked or impassable during the winter storm months. Because of our proximity to the mountains and the rugged terrain, we are limited in the number of LZ's for Airlift and since Airlift comes from Seattle, we are looking at a minimum 1 hour response for airlift.

I have ALS support from a private ambulance company that is generally 30 minutes away. One of our most common scenarios is to be dispatched to an ALS call, Respiratory Distress, Cardiac Event, Multi-system Trauma, something that in a perfect world, would get an immediate ALS response. But, instead of nothing, they get to be driven to the hospital, or towards ALS with someone skilled in CPR, able to use a BVM or OPA, Combi-tube. We respond with an ambulance, which has an AED, O2, bandages and dressings, splints and backboards. While none of this alone will heal what bothers them, it sure ups the odds that they arrive at ALS or the local hospital with a higher chance of survival than if they tried to drive themselves to the hospital in their car.

The comparison between BLS and ALS doesn't take into account those areas and situations where the choice is BLS or nothing. But then, that's your free market system at work!

 

[skyemt]

Bossycow, i don't think anyone would endorse nothing over emt-b...
but if you could, wouldn't you prefer higher level provider for a chest pain call? of course you would...

and with regards to all the talk about not being able to find studies... would anyone really spend much money to see if higher trained paramedics dealing with priority emergent patients would have better outcomes than lower trained providers dealing with priority emergent patients???

kind of obvious answers, no? who the heck would spend money on that study...

i still fail to see why the emt-b vs. paramedic debate still rolls on... can we not be so insecure?

i do get it, that some won't have the time or resources to become a paramedic... but that will leave you at the Basic level, and no study will change that... i would rather try to be the best emt-b provider, and search out studies on how to do that...

 

[Aileana]

wow...9 pages of drama, from over such a short period of time...guess this is a fairly sensitive area *dodges flying keyboards in response to commentary*.
The system we have here in Canada is a bit different, and it seems to be rather effective. We don't have EMT levels (as far as I know, atleast), but we have PCP (Primary Care Paramedics) and ACP's (Advanced Care Paramedics). To become a PCP, you need typically 2 years of college education, and to pass the A-EMCA (similar to the National Registry, I believe...a test that allows one to work as a paramedic in Ontario). For some regions, there is further testing, and you are ranked out of all of the applicants, and from these standardized scores and interviews, regions do their hiring.
PCP's are allowed to do all the basic treatment, start IV lines (in some regions, depends though), defibrillate, interpret ECGs (I believe) and give 6 symptom relief meds. ACP's can do all of those, plus a lot more. We also have CCP's, but I have yet to encounter any of them, so I am not too sure about their role.

In the region I am riding out with now, they seem to be aiming towards having an ACP and a PCP on each rig. Once, I was lucky enough to ride third with two ACP's (though one was consolidating). They're definately an asset in patient care, especially in pain management, I find. Also, with ACP skills being administered quickly (not having to worry about another line of communication in requesting backup), many potentially fatal incidents are deferred quickly. For example, the SVT call we did a while back, if there was not an ACP on board to give adenosine, the patient may have not made it to the hospital.

Sorry if I've gotten a bit off-topic/rambled (again) here, but I guess I was pointing out that here we have an example of what a bit more education does to help the public.
*hides in corner, prepares to be flamed*

 

[emt/ff71185]

I cannot say that I am proud to have started this whole mess of a thread but it has taught me a lot about the topics that fire up EMS personnel. I never knew of the feud that exists between EMT-B's and Paramedics. I still cannot quite figure out if it is because EMT-B's try and be more than they are or that Paramedics forget that they started as EMT-B's and get a little too big of a head. It is probably a combination of both. Regardless of the reasons for it we all need to remember as Rid said that we all share the same goal of providing the best patient care we can. Every one of us is part of the same system and some will change there level of education and some will not and it does not really matter in the end because we all are helping in our own way.

 

[ffemt8978]

I cannot say that I am proud to have started this whole mess of a thread but it has taught me a lot about the topics that fire up EMS personnel. I never knew of the feud that exists between EMT-B's and Paramedics. I still cannot quite figure out if it is because EMT-B's try and be more than they are or that Paramedics forget that they started as EMT-B's and get a little too big of a head. It is probably a combination of both. Regardless of the reasons for it we all need to remember as Rid said that we all share the same goal of providing the best patient care we can. Every one of us is part of the same system and some will change there level of education and some will not and it does not really matter in the end because we all are helping in our own way.

And that's the reason why the CL's haven't closed this thread yet. While it has been an emotional topic, everyone has done an excellent job of staying within the forum rules and keeping it civil.

 

[BossyCow]

Bossycow, i don't think anyone would endorse nothing over emt-b...
but if you could, wouldn't you prefer higher level provider for a chest pain call? of course you would...

..

Of course, and I've stated so repeatedly. The point I was making is that there are still many areas, most of them rural where ALS is not an option due to financial considerations.

 

[skyemt]

of course, ALS is not available in many places... however, that doesn't mean we should have a comparison between BLS and ALS...

if there were enough ALS providers to staff all the crews, would there be BLS??

of course there would be BLS, but practiced by Paramedics when ALS is not required...

i think what gets lost here is the fact that BLS/ALS refer to "standards of care", not to reflections on the abilities of individual providers...

BLS is necessary and practised by all levels of providers, not just emt-b's...
but if more is needed, the advanced care provider can provide it... it is the continuum that Rid referred to earlier...

try not to take things personally... if there were enough Paramedics to staff ambulances, EMT-B's would just be driver/helpers... one of the only reasons EMT-B's exist is precisely because there are not enough ALS providers, due to time, expense, and all the other reasons stated out here a million times...

 

[BBFDMedic28]

Were still on this topic? thats awesome.

 

[BossyCow]

I'm sorry, was I taking it personally? I believe my posts were simply responding to the ALS will be everywhere comments. Would I like to have it? Sure... Would I support it? Absolutely! But its naive to imply that all systems are heading that way. Population density is a huge factor that is often overlooked by those practicing in the more urban environs.

 

[skyemt]

well, it's just that saying rural areas often don't have ALS, so BLS is helpful, is kind of obvious, no?

no one said ALS is everywhere...

i'm not really sure what you are trying to add to the mix here...

 

[BossyCow]

It seems to me that there is a immediate jump that all EMT-Basics will or should eventually become medics. This is not a reality in rural areas. If there were criteria that agencies converted to ALS, many of them would simply choose not to provide service at all. We even had a district drop their ALS and go to BLS.

Very often on this topic, those practicing in densely populated areas assume their reality is ours. I am merely 'adding to the mix' my reality.

 

[DisasterMedTech]

Because it's true and often, we who have made every mistake in the book, become intolerant of those who make every other mistake in the book. It's something about preserving ego by making others appear less bright than ourselves. Very human.We have no choice but to make mistakes. We can either resist being told, or take in the info and use it to get better. Attacking has as little value as defending. Tolerance of the learning curve is important to everyone here, because if we're not all learning and making mistakes behind it, then we're not getting more proficient.

I think this notion also comes from alot of the same folks that assume that all EMT-Bs want to be paramedics. Its like saying all nurses really want to be doctors or all dentists are really frustrated maxillo-facial surgeons. Do I want to eventually become a paramedic. Sure. But maybe 4 or 5 years down the road. Since I got involved in disaster/MCI response I am more interested in becoming the best BLS/BTLS provider I can. Since I have access to them at no charge, I do take some courses, like AHLS, that provide alot of information I cant use because it has to do with tx that are not in my protocol, but its not going to hurt anything to have some knowledge about VX gas exposure s and sx. Right now, Im more worried about getting my MS degree done in Disaster Medicine. Then maybe Paramedic school. The interesting thing is that it is an unwritten, but not often unspoken, rule, that we as Basics defer to our Paramedic partners on everything. What happens when I am working with a paramedic who doesnt have the level of MCI/Disaster response training than I have. I think I have been asked a question once by a paramedic who was 10 years younger than I am and I think the question was "do we have any more 4 x 4s?" Just because you have the title, doesnt mean you have all the information, answers or solutions in the world, but I think there is a feeling among Paramedics that if they ask a question, their Basic partner will think less of them, whereas they should be asking whatever it takes to render the best patient care.