Finally ! Someone who cares about BLS and EMT's

[eynonqrs]

The other day I was reading the JEMS article about BLS being an afterthought. I can't agree more with it. I have been in this field for almost 18 years now, and I have seen alot of changes. For one, they way the state that I am from [PA] is teaching EMT's is horrible.. this is no joke, for a stubbed toe, call ALS. WTH ???? New EMT's that I see are horrible, they have no skills. When I took my EMT, we were shown the proper way to do stuff and we had to observe in the Emergency Room at a hospital for so many hours. Yet, to be a paramedic in this state you need only be an EMT for 6 monts. How can one be a good paramedic when one is a lousy EMT? Heck, when I stared in working for a paid service in 95, I had to do so much ride along time and prove that I had the skills, same held true for my volunteer service. The county that I reside in is messed up, too. They dispatch ALS for about everything. Since when is a high temp in adults ALS ? I can understand why for Peds for the risk of seziures. Since when has a hop FX become ALS ? I can go on and on about it... The EMT can't get no skills because when they get there [the BLS rig] all they are doing is getiing a stretcher and that is it. The county that I am from ALS is ran by three private services, and there have been times where there is no ALS. Or there has been one ALS unit that was available and got sent to the middle of nowhere for a High Temp or Nose Bleed. What if someone called 911 and needed ALS for a true critical call and died beacuse of it ??? Most hospitals in the county where I am from are in the 10 to 15 min range, unless you are in the rural sections. It truly amazes me that the hospital ER staff will :censored::censored::censored::censored::censored: if you come in BLS with a fracture... "oh, why didn't you start an IV ?" well they are too dam lazy to do it themselves. They only way EMT's get any skills is if you work or volunteer in a rural area where ALS is 20 to 30 min away. Hell, I say why do we need fancy BLS ambulances with all that equipment that we are required to carry that we don't use ? I say BLS should go back to the days of the caddie ambulances and all you needed was FA/CPR. Sorry about the rambling, but this article makes sense and it makes me angry that no one has faith in EMT's or want's to give any time or effort to make them work on thier skills !

 

[Lifeguards For Life]

The other day I was reading the JEMS article about BLS being an afterthought. I can't agree more with it. I have been in this field for almost 18 years now, and I have seen alot of changes. For one, they way the state that I am from [PA] is teaching EMT's is horrible.. this is no joke, for a stubbed toe, call ALS. WTH ???? New EMT's that I see are horrible, they have no skills. When I took my EMT, we were shown the proper way to do stuff and we had to observe in the Emergency Room at a hospital for so many hours. Yet, to be a paramedic in this state you need only be an EMT for 6 monts. How can one be a good paramedic when one is a lousy EMT? Heck, when I stared in working for a paid service in 95, I had to do so much ride along time and prove that I had the skills, same held true for my volunteer service. The county that I reside in is messed up, too. They dispatch ALS for about everything. Since when is a high temp in adults ALS ? I can understand why for Peds for the risk of seziures. Since when has a hop FX become ALS ? I can go on and on about it... The EMT can't get no skills because when they get there [the BLS rig] all they are doing is getiing a stretcher and that is it. The county that I am from ALS is ran by three private services, and there have been times where there is no ALS. Or there has been one ALS unit that was available and got sent to the middle of nowhere for a High Temp or Nose Bleed. What if someone called 911 and needed ALS for a true critical call and died beacuse of it ??? Most hospitals in the county where I am from are in the 10 to 15 min range, unless you are in the rural sections. It truly amazes me that the hospital ER staff will :censored::censored::censored::censored::censored: if you come in BLS with a fracture... "oh, why didn't you start an IV ?" well they are too dam lazy to do it themselves. They only way EMT's get any skills is if you work or volunteer in a rural area where ALS is 20 to 30 min away. Hell, I say why do we need fancy BLS ambulances with all that equipment that we are required to carry that we don't use ? I say BLS should go back to the days of the caddie ambulances and all you needed was FA/CPR. Sorry about the rambling, but this article makes sense and it makes me angry that no one has faith in EMT's or want's to give any time or effort to make them work on thier skills !

The "ALS/BLS" (where else in medicine is there ALS and BLS? Is there such a thing as a BLS physician?) divide is simple. Is this patient going to see a physician in an emergency room? Then the patient deserves at least an assessment by a paramedic due to the extreme difference in education, training, diagnostic tools and interventions between basics and paramedics.

Hip fracture patients and adults with high fevers can not be accomodated properly at the Basic level. The hip fracture patient may be best suited with meds for pain managment, the adult with a high fever may benefit from intravenous fluids and/ or medications.

 

[zmedic]

I think fractures should be ALS. It's not about the ER not wanting to start IVs. It's about the fact that giving pain meds in the field for fractures is really one of the few cases where EMS can make people feel a lot better on the way to the hospital.

 

[JPINFV]

They dispatch ALS for about everything. Since when is a high temp in adults ALS ? I can understand why for Peds for the risk of seziures. Since when has a hop FX become ALS ?

Callers lie. Sepsis. Pain control.


Also, as far as experience, why don't other health care fields require work at a lower level? It's strange how the vast majority of my fellow students don't have any certifications or licenses prior to starting med school.

 

[Lifeguards For Life]

Callers lie. Sepsis. Pain control.


Also, as far as experience, why don't other health care fields require work at a lower level? It's strange how the vast majority of my fellow students don't have any certifications or licenses prior to starting med school.

just out of curiosity, do you feel your training and experience as an EMT give you an upper hand in med school?

(not trying to pick on you, just wondering)

 

[JPINFV]

Maybe a little bit in the class that covers physcial exams and the like (Essentials of Clinical Medicine), but it's equally a liability. On one hand, I'm more comfortable working with standardized patients and obtaining a history and physical. On the other hand, I'm just as likely to go off on something (e.g. had an SP comment that a BP was lower than normal and I was reassuring him that it was still a good BP. He commented afterwards that he wanted to tell me to move on since the encounters have a time limit and I was eating up precious time).

 

[Lifeguards For Life]

is this the article you mention?

http://www.jems.com/news_and_articles/articles/jems/3412/back_to_basics.html

 

[eynonqrs]

http://www.jems.com/news_and_articles/articles/jems/3412/back_to_basics.html

Yes it is, thank you for the link. I agree with the article 100%.

 

[JPINFV]

To bad the article is mostly junk. The only reasonable valid issue is paramedic saturation, and even then, that's when you have 5-6 paramedics responding to a call, not just straight up having 2 paramedics respond to all 911 calls.

 

[Aidey]

Callers lie. Sepsis. Pain control.


Also, as far as experience, why don't other health care fields require work at a lower level? It's strange how the vast majority of my fellow students don't have any certifications or licenses prior to starting med school.

Exactaly. RNs aren't required to spend time as CNAs or LPNs before they can go to RN school. Paramedic schools could be easily modified to include all of the curriculum that the EMT B class cover.

just out of curiosity, do you feel your training and experience as an EMT give you an upper hand in med school?

(not trying to pick on you, just wondering)

I've known a couple people who are in med school, or are planning on applying. Previous patient care experience can give you "brownie points" at some schools. Some PA schools also require a certain number of patient contact hours before you can apply (The school my co worker just got into does at least).



I will agree with the ideas that we need to start at the beginning and then move towards the advanced, and we need to make sure we are remembering our assessment skills, but this article is just going to inflame the BLS vs ALS debate even more.

As stupid as it sounds, you don't know why the caller stubbed their toe until you get there. Is it because they became dizzy and lost their balance, or suddenly lost sight in one eye? Fevers and fractures are also two things that definitely deserve "ALS" assessment and probably intervention. The pt has a fever for a reason, and that underlying reason may need some serious interventions to keep the patient alive (My last "flu like symptoms" dispatch arrested on the way to the hospital. The guy was 40).

 

[Lifeguards For Life]

Yes it is, thank you for the link. I agree with the article 100%.

what interventions would you want for a patient with a (for discussion let's say a confirmed a type II Intertrochanteric fracture, in a 60 year old female, following a trip over a curb); BLS procedures only?

 

[So. IL Medic]

(where else in medicine is there ALS and BLS? Is there such a thing as a BLS physician?)QUOTE]

Yep. It's called a P.A.

 

[So. IL Medic]

Callers lie. Sepsis. Pain control.


Also, as far as experience, why don't other health care fields require work at a lower level? It's strange how the vast majority of my fellow students don't have any certifications or licenses prior to starting med school.

Around here, all nursing students must start as CNAs now.

 

[Aidey]

True BLS skills—from patient positioning and vital signs to providing oxygen, from bandaging and splinting to placement of airway adjuncts, from the physical examination to spinal immobilization—should ideally be performed by BLS personnel whenever possible, leaving the ALS personnel to perform ALS interventions and formulate a treatment plan based on a diagnostic impression.

This actually makes me mad, now that I've read it again. It makes it sound like BLS skills are below Paramedics and we just need to focus on the major stuff. It also makes it sound like Paramedics are one-hit-wonders only good for interventions.

What paramedic out there is going to perform an intervention without doing any of those things themselves? How can I form a diagnostic impression when physically examining the pt is apparently my partner's job and not mine. No offense to EMTs but Paramedics are taught more advanced physical assessment techniques, and in some cases an EMT may not know something they are looking at is significant.

I'm going to be the one writing the report and giving report to the hospital. Even if I don't perform an exam or procedure myself, you can be sure I'm watching it if at all possible. Even with something like an oral airway. If an oral airway is going in, chances are the pt is getting intubated. Putting in or watching the oral airway be put in gives me an additional chance to look at the pts oral anatomy and helps me decide what tools I will need.

That all being said, I trust my partner and I have a good understanding of his knowledge base. He understands that even though I trust him, I still like to see things for myself. If he finds something strange he will get my opinion, and it's not at all uncommon for me to ask his opinion when I find something strange. Or ask his opinion on how to describe something. At the same time though, if my partner palpates something and the patient screams and he states he feels crepitice, I'm not going to poke at it too.

 

[Lifeguards For Life]

This actually makes me mad, now that I've read it again. It makes it sound like BLS skills are below Paramedics and we just need to focus on the major stuff. It also makes it sound like Paramedics are one-hit-wonders only good for interventions.

What paramedic out there is going to perform an intervention without doing any of those things themselves? How can I form a diagnostic impression when physically examining the pt is apparently my partner's job and not mine. No offense to EMTs but Paramedics are taught more advanced physical assessment techniques, and in some cases an EMT may not know something they are looking at is significant.

I'm going to be the one writing the report and giving report to the hospital. Even if I don't perform an exam or procedure myself, you can be sure I'm watching it if at all possible. Even with something like an oral airway. If an oral airway is going in, chances are the pt is getting intubated. Putting in or watching the oral airway be put in gives me an additional chance to look at the pts oral anatomy and helps me decide what tools I will need.

That all being said, I trust my partner and I have a good understanding of his knowledge base. He understands that even though I trust him, I still like to see things for myself. If he finds something strange he will get my opinion, and it's not at all uncommon for me to ask his opinion when I find something strange. Or ask his opinion on how to describe something. At the same time though, if my partner palpates something and the patient screams and he states he feels crepitice, I'm not going to poke at it too.

the article did not seem to acknowledge that paramedics are EMT's as well

 

[eynonqrs]

what interventions would you want for a patient with a (for discussion let's say a confirmed a type II Intertrochanteric fracture, in a 60 year old female, following a trip over a curb); BLS procedures only?

BLS procedures:

I would fully immoblize pt with a c-collar, cid's, and use a scoop stretcher [they are good for hip fx's] if a scoop stretcher was not available I would use a backboard. I would also make sure the pt is secured properly to avoid movement of the leg to avoid further injury. I would constantly monitor vital signs every ten minutes as I would for any trauma pt.

 

[Lifeguards For Life]

BLS procedures:

I would fully immoblize pt with a c-collar, cid's, and use a scoop stretcher [they are good for hip fx's] if a scoop stretcher was not available I would use a backboard. I would also make sure the pt is secured properly to avoid movement of the leg to avoid further injury. I would constantly monitor vital signs every ten minutes as I would for any trauma pt.

ok. your patient is in severe pain, and is scared of losing her independence, and ability to perform daily activities. Do you feel her needs may be better met by a clinician who can provide her with pain management on a (15-20 i believe you said in the original post) minute transport to definitive care?

Lets say that when you reassess her vitals she has become, tachycardic, tachypnic, hypotenisve, and has become cool, pale and diaphoretic.
People with an intertrochanteric hip fracture may become light-headed or weak or even go into shock. these hip fractures can damage blood vessels and cause bleeding inside the hip.

Are there any ways this patient could possibly beneift from a BLS transport as opposed to an ALS transport? what patient do you feel would benefit from BLS over ALS?

 

[Aidey]

Good luck, hopefully you will recover quickly from the concussion you get after moving her without any pain control and she whacks you with her cane/purse/pot/pan/whatever is handy.

Ok. That was unfair, I admit it. Not all fracture patients want pain meds, but you will definitely come across those that won't even let you touch them until you've given them some pain relief.

In addition to what L4L said, the patient may have other injuries that become apparent later on. A hip fracture is definitely a distracting injury.

You should also never believe a patient who tells you they tripped and fell until you've fully assessed them for medical reasons for the fall.

"So what happened here today ma'am?"
"Oh I just fell over and hit the floor"
"What made you fall today?'
"Well, I started feeling funny and then I felt like someone kicked me in the chest and it knocked the wind out of me and then I just fell over" (Anyone guess what that was?)

 

[daedalus]

Every patient that goes to the ED is eventually seen by the physician or PA. Why does EMS think that just because someone stubbed a toe, they should get seen by the lowest level provider?

Paramedics are *supposed* to be experts in prehospital medicine. They should probably be dispatched to most 911 calls.

Also, a fever is very much an "ALS" complaint. Can an EMT describe the mechanisms of fever, examine for causes, and understand the critical nature of infections in certain populations?

 

[VentMedic]

Around here, all nursing students must start as CNAs now.

All nursing students (in many states) can become CNAs. I have not seen any change in the legislation in the states where that is mandatory to become an RN.

(where else in medicine is there ALS and BLS? Is there such a thing as a BLS physician?)QUOTE]

Yep. It's called a P.A.

Is that why they are called "assistants"? Aren't CNAs "assistants" also? Is that like a BLS RN?