is "ALS" a lie?

[Melclin]

I knew there was something I forgot.

Some tout pre-hospital ultrasound as the next big thing. Is it cool to do?... of course. How will it really change the game? Will the patient be treated any differently? I only see it as a triage tool but since we already over triage as a safety net I don't see any real difference between having ultrasound or not having it in the field. If you suspect internal bleeds, tamponade, pneumo, or whatever, transport to the trauma center and treat based on PE findings which in those cases should be very obvious. Trauma centers and most other hospitals have bedside ultrasound that is on the patient within moments of arriving anyway.

I'm not expert in US but I see it as being similar to prehospital 12 lead. Similar in the sense that it requires a considerable increase in education plus the funding for equipment. How much does a prehospital 12 lead change things? Sometimes. Its still a standard of care for top tier providers. STEMI alerts, risk strat of chest pain, posterior/inferior infarct recognition to avoid nitrates, generally good tool to investigate a number of different pathologies. 10-15 years ago, I wouldn't blame people for saying Chest pain = MONA + transport anything else is a bit beyond EMS and how much difference will 12 leads make anyway.

Dr Smith's ECG blog is full of stories about bed side echo aiding diagnosis of MI.

You don't think abdo pain is something we could investigate with US?

There aren't really any sure fire ways of identifying thoracic and abdominal aneurysms based on hx/physical. Ruptured ectopic pregnancy. The triage advantages are obvious as are the benefits in long transports. Taking someone to the appropriate hospital for their condition is a valuable thing. Its the difference between taking your 43 year old female with abdo pain to the local hospital ?renal colic or taking her to a major hospital with a clear picture of the ruptured ecto pregnancy. Real job.

Assessing volume status in ?septic pts or dehydrated pts.

We've had a bit of trouble with missing tension pneumos in the field. Not through poor clinical skills, just because of odd presentations/being hidden behind very otherwise sick pts. To the extent that there was some talk of prophylactic popping of chests in certain groups of trauma pts. Could we not be using US to identify pnemos. Which of course you mentioned, so I don't see how you are missing the benefits of identifying that.

There is also talk of certain abdo trauma/suspected haemorrhage being added to the list of situations when you should be judicious with fluids, a la penetrating truncal trauma. I imagine US would be useful in decision making in this regard.

I've also read that there is no reason why US can't be done on the road or in the air, so it doesn't necessarily increase scene times.

 

[Veneficus]

Dragging EMS out of the 20th centrury.

US EMS currently operates in an industrial age mentality.

(A good job is one where you know yor skills and the bossman tells you what to do. As long as you do what your told, you are doing a good job regardless of outcome.)

But that was more than 100 years ago.

At what point do you say "that doesn't benefit anyone anymore?"

At what point does the value of your EMS service become so marginal that you are not worth what you are paid now?

EMS as it currently stands, will never have pay equal to police and fire. You know why?

It is not worth it.

It is jst an expensive taxi ride. The educational demands can be completed in roughly 6 weeks.

Now the providers claim to be saving lives, and in some cases it is true. But how many? Enough to justify the expense?

If all it is is a ride, it is the paramedic that is the uneeded part of EMS. Not the basic.

Imagine the cost savings of switching all ALS ambulances in the country to BLS.

Look at the countless posts where members state an experienced basic can do just as well as a paramedic. (Not saying that is true) but if that is the perspective of the providers, what is the perspective of the public?

One of the major points of the OP is that there is no doubt why cardiac surgeons and anesthesiologists are paid what they are.

There is all kinds of doubt as to whether EMS providers deserve anything more.

At 40 hours a week, in 3 weeks you could create an entire class of EMTs who can follow orders without thinking.

As was pointed out by Rid, and is apparent here, everytime somebody suggests adding something new, it is met by "That doesn't help or matter."

It is like modern US providers are hell bent on arguing the latest medicine doesn't matter to them.

It is like cutting your own throat and wondering why nobody gives you more for it.

I don't suggest a massive strike either. Since most of the payment comes from people who don't use the ambulance it would very effectively point out people can get along without you.

 

[usalsfyre]

I love this line that I heard from a medic once

Don't listen to this guy, he's an effin idiot

"If EMS would strike for 7 minutes all over the US at the same time. Everything would go to hell

See my post elsewhere about seriously overestimating your value to the system. In many(most?) areas of the US, 7 minutes wouldn't even be noticed, as no calls would even be received. Large cities often have hours worth of call backlogs. Can you please explain to me how in 7 minutes is going to "go to hell"?

and we'd get the pay we want."

Does he think reimbursement is going to magicly increase? What else has he got in his fantasy land? Did he at least share whatever he was on? :wacko:

 

[MrBrown]

Brown is down a vial of ketamine, perhaps that explains a lot?

 

[Veneficus]

Clibb,

I am not picking on you or anything, but the comments here are exactly the reason I argue that people should not get "experience" at the EMT level before moving on to a higher healthcare role.

Be careful who you pick up as a mentor or look up to. It could have a very negative effect on your future. Especially in medicine, where many hold EMS persons in outright contempt for some of the absolutely stupid positions they advocate.

 

[rescue99]

I love this line that I heard from a medic once, "If EMS would strike for 7 minutes all over the US at the same time. Everything would go to hell and we'd get the pay we want."

I don't know about 7 minutes but it may be the end result...at first.

 

[Jon]

Wow. This is some really good food for thought.

Now that I've been practicing as a medic for a while, I'm finally starting to get the hang of this, I think.

I still follow my protocols. I also will occasionally check them on a call for the 2nd or 3rd line orders I never use. For example, we have orders for benzodiazepines after Zofran in serious nausea/vomiting. Only ever had to do it once (and my partner did it again last night).

I'm all about treating the patient to the limits of my protocols before I call a doc, and often my calling the doc is really a "protocol says I need to talk to you... but I'm not looking for any orders... Here's my ETA... Bye."

What I find is funny is that there are many medics in my area that call a doc before doing things clearly allowed by protocol - like narcs for extremity trauma. Why? Because they aren't comfortable w/o having direct orders.

 

[medicRob]

I remember a specific lecture in nursing school, the course was called, "Intro to Professional Nursing" where we learned the history of our profession, the types of nurses (ADN, BSN, MSN, DNP, DSN), and the roles these nurses play in our profession as a whole. We spoke with regard to the hallmarks of a profession and the point at which a job becomes a profession. Position, Job, Occupation, Professional, and professionalism are all different things.

To quote an excerpt from "Nursing Now" by Catalano:

"Position: A group of tasks assigned to one individual

Job: A group of positions that are similar in nature and skill that can
be carried out by one or more individuals.

Occupation: A group of jobs that are similar in type of work and that are usually found through an industry or work environment.

PROFESSION A type of occupation that meets certain criteria (discussed later in this chapter) that raise it to a level above that of an occupation. "


Now on to those criteria..

1. High Intellectual level of functioning.

2. High Level of individual responsibility and accountability

1. Does this individual have enough knowledge to be held liable?

3. Specialized Body of Knowledge

1. A profession no longer relies on how things are "Traditionally done" but rather on what the latest science is and what is working...

4. Evidence-Based Practice

1. The institutions responsible for the training and professional development of the paramedic need to introduce the individuals to the latest research and findings while the licensing (yes I said licensing) boards create new laws allowing for more autonomy in EMS, giving them the tools and the means to SAFELY and effectively render evidence-based care rather than following "cook books".

How many peer-reviewed academic journals are there in nursing where nurses are writing the articles and performing the research?

How many peer-reviewed academic journals are there in paramedicine where the EMT-Ps are writing the articles and performing the research?

We need to strive to go from an occupation to a profession, but to do this we will be required to make some drastic changes to the way we educate paramedics as well as redefine paramedicine as a whole.

 

[Veneficus]

SAFELY and effectively render evidence-based care rather than following "cook books".

Here is unfortunately where I see the shortfall in nursing and do not think it will benefit EMS to emulate it.

Evidence based practice is not the end all be all of medicine. It is practice most likely to help a given condition. It is based on epidemiology and should be the likely starting point in most cases. It doesn't mean it will work for any given patient.

Following these guidlines as the rule of best practice is cookbook medicine.

It is why I have seen nursing journals that criticize physicians for starting outside of these practices. Something that may very well be indicated or an acceptable treatment plan.

Treating people by epidemiology while useful and often neccesary doesn't mean you are doing what is best for any given patient. Nobody should mistake it as such.

I asked one of the more respected and knowledgable cardiologists here why she is so set against paramedics and ALS not performed by physicians. Her answer left almost no room for an argument.

The long and short of it is they overtreat. Everything is an emergency to them.

Now whether you are following standing orders or the results of the latest study, you are still doing the same thing. Disguising it with different terminology doesn't fool any medical professional.

Getting the best treatment for the individual is why people still seek out physicians. It is why when you go to a "midlevel" provider, you are basically resigning to hopefully falling into the epidemiology or settling for less. (In my experience nothing more than an overeducated protocol monkey doing no more or less than a paramedic)

When creating this "evidence based guidline." (aka protocol) where do you draw the line at acceptable losses? 10%, 20%, 40%, of total patient population with a given affliction?


How do you account for multiple disease processes? Certainly not treating each one like the other doesn't exist.

How do you account for things like inability to afford a given treatment? Just tell them they are out of luck?

What if they have reservations about a given treatment? Do you just not help them?

What about conditions where no known treatment exists?

Where no treatment is shown to be effective?

Just give up on them?

Of course not, you take them to a doctor who will make something up based on raw knowledge, not an evidence based guidline. Because one doesn't exist.

I think many healthcare professions are attempting to condense their vast bodies of knowledge into over simplified "guidlines" and try to give them more credibility than they are worth by assigned terms like "evidence" instead of "protocol."

This evidence, has various levels of value and utility. It is a tool in the box. Not a substitute for knowledge. Not a substitute for the best care. Not a substitute for individual care.

It is madness to try and industrialize medicine. It has been tried. It has failed in all respects. From Dx to treatments, to cost, to patient results. Especially in the US where the cost/result ratio is one of the most disproportionate in the modern world. So much so the whole system is on the brink of collapse.

If EMS is to be a profession, because the delivery method is not the same as a hospital, it will require more raw knowledge and more evidence based practices. But there is the rub, despite evidence against some practices they remain. The evidence for new practice disproportionate to old.

I guess it has to be made simple for the masses.

 

[clibb]

Clibb,

I am not picking on you or anything, but the comments here are exactly the reason I argue that people should not get "experience" at the EMT level before moving on to a higher healthcare role.

Be careful who you pick up as a mentor or look up to. It could have a very negative effect on your future. Especially in medicine, where many hold EMS persons in outright contempt for some of the absolutely stupid positions they advocate.

That totally depends on where in healthcare you want to work. If you want to work in the ER, then it's a good choice to get experience on the streets.
Now, I do look up to some of the medics I have. The one who stated that is an EXCELLENT medic. I bet you anything that medic is better than a90% of the medics on this forum. Blunt statement? Maybe. But, if you compare EMS to an industrial branch of the workers system in the US, like Veneficus did. You will see unions that have gone on strikes. Now, there is no unions for EMTs or Medics, but nurses have one of the strongest unions in the US. So if people want to run EMS as a industrial business, then what would happen if all of EMS went on strike? Nothing good. I'm just saying, "What if".

Now Veneficus, you know I wanna be a doc. So of course I wouldn't have a medic as a career mentor.

 

[TransportJockey]

That totally depends on where in healthcare you want to work. If you want to work in the ER, then it's a good choice to get experience on the streets.
Now, I do look up to some of the medics I have. The one who stated that is an EXCELLENT medic. I bet you anything that medic is better than a90% of the medics on this forum. Blunt statement? Maybe. But, if you compare EMS to an industrial branch of the workers system in the US, like Veneficus did. You will see unions that have gone on strikes. Now, there is no unions for EMTs or Medics, but nurses have one of the strongest unions in the US. So if people want to run EMS as a industrial business, then what would happen if all of EMS went on strike? Nothing good. I'm just saying, "What if".

Now Veneficus, you know I wanna be a doc. So of course I wouldn't have a medic as a career mentor.

Really EMS doesn't have unions? I guess NEMSA is a figment of my imagination. Along wiht the *shudder* IAFF EMS division *shudder*.
And I can tell you that even if EMS went on strike there are providers who actually care about their patients that most likely cross the picket lines to ride the rigs and provide care.

 

[Veneficus]

That totally depends on where in healthcare you want to work. If you want to work in the ER, then it's a good choice to get experience on the streets.

What makes you say that out of curiosity?

 

[abckidsmom]

What makes you say that out of curiosity?

Because if it's your life's ambition to stock rooms, get vitals, run labs and start IVs, you should definitely spend a significant period of time driving a truck, loading and unloading a stretcher, and eating McDonalds.

All the great ED techs lay their foundations this way.

 

[clibb]

Really EMS doesn't have unions? I guess NEMSA is a figment of my imagination. Along wiht the *shudder* IAFF EMS division *shudder*.
And I can tell you that even if EMS went on strike there are providers who actually care about their patients that most likely cross the picket lines to ride the rigs and provide care.

Sorry, didn't know we had those. *Zipping mouth, locking, and throwing key away*

 

[Veneficus]

Because if it's your life's ambition to stock rooms, get vitals, run labs and start IVs, you should definitely spend a significant period of time driving a truck, loading and unloading a stretcher, and eating McDonalds.

All the great ED techs lay their foundations this way.

I started that way

ED tech was the best paramedic job I ever had. The hospital required a year of busy field experience to apply. Otherwise I would have been more than happy to go right from school to ED tech. As it turned out, there were several years in between.

But I mean from the medical standpoint.

Perhaps what has led to my successes in medicine has been my time having to actually make decisions on the road. They were not particularly involved decisions, but I don't have any peers in my class who can prioritize the vast amount of medical information so quickly when dealing with live (or dead) patients.

I am also really practiced at physical exam skills and history taking.

I have a couple of psychomotor skills I am rather adept at too. Like intubation and line placement.

But all of that comes from being a medic, not a basic. I cannot really think of anything in my EMT-B education or experience that has had any impact on my medical successes.

Perhaps others have had a different experience and would share it with me?

 

[Veneficus]

Really EMS doesn't have unions? I guess NEMSA is a figment of my imagination. Along wiht the *shudder* IAFF EMS division *shudder*.
And I can tell you that even if EMS went on strike there are providers who actually care about their patients that most likely cross the picket lines to ride the rigs and provide care.

You forgot AFSCME and Teamsters.

 

[firetender]

But all of that comes from being a medic, not a basic. I cannot really think of anything in my EMT-B education or experience that has had any impact on my medical successes.

Perhaps others have had a different experience and would share it with me?

I'm a hound on this and it's probably a 50/50 split on opinions, but there are innumerable logistics that need to be handled on the scene of an emergency, often times the least critical of which have anything to do with advanced intervention.

It is an ART form where you are turning chaos into order. To minimize the importance of handling and then learning to MASTER all those niggling little details, primary of which is COMMUNICATION, is like saying the job is like re-stocking shoe store shelves.

It ain't, it's about creating a space to work, maintaining its integrity, and then moving a human being from one safe space to another.

Now screw the paramedic stuff and bring these skills -- this way of THINKING and ACTING-- into the outside world. What do you get? You get people who, with no more experience than in BLS, but trained by continual exposure and repetition -are capable of quick, responsive observation followed through by ACTION.

Lives get saved that way. They get damaged by inattention to those details deemed so irrelevant.

I don't think I need to belabor the point. Part of the problem is we don't take the time to acknowledge just how important each phase is and how its contribution is essential to being able to act effectively at the next level.

Vene, every foundational step of your in-hospital management of a crisis -- the same crisis' your MD-in-training colleagues fumble through -- is stuff you don't even have to think about anymore because it was ingrained in you while you were a hack.

 

[abckidsmom]

I started that way

ED tech was the best paramedic job I ever had. The hospital required a year of busy field experience to apply. Otherwise I would have been more than happy to go right from school to ED tech. As it turned out, there were several years in between.

But I mean from the medical standpoint.

Perhaps what has led to my successes in medicine has been my time having to actually make decisions on the road. They were not particularly involved decisions, but I don't have any peers in my class who can prioritize the vast amount of medical information so quickly when dealing with live (or dead) patients.

I am also really practiced at physical exam skills and history taking.

I have a couple of psychomotor skills I am rather adept at too. Like intubation and line placement.

But all of that comes from being a medic, not a basic. I cannot really think of anything in my EMT-B education or experience that has had any impact on my medical successes.

Perhaps others have had a different experience and would share it with me?

I was having an extreme bout of sarcasm. Don't think there's a single thing in the world wrong with being an ED tech. It is a good time, with lots to learn, but spending time on a BLS ambulance doesn't prepare you for it any more than an hour or two touring the ED could.

I've experienced what you're talking about, being the only one who can prioritize decisions and do a few skills, I think that just comes from already having jumped over the edge of talking to a patient, making decisions for a patient, and doing things to and for the patients.

I'm seen good BLS providers who can do the same, though, and quickly get over that hump in other educational settings.