Is "ALS" level care a "forbidden fruit?"

JPINFV

JPINFV

Gadfly
Messages
12,681
Reaction score
197
Points
63
We constantly hear the cliches such as "BLS before ALS," "basics save paramedics," "paramedics waste too much time doing their ALS skills," and a bunch of other sayings. I recently had an interesting thought on the matter (it happens from time to time, I swear).

How much is the ALS v BLS debate rooted in the forbidden fruit metaphor. Lower level providers see a higher level provider doing something (for the whole spectrum, first responder through physician) and the lower level wants to do the skill. When they are finally allowed to preform the skill (change of scope or change in level), they tend to look for every opportunity to preform their new skill, much to the dismay of their patients. Hence, the provider is said to have "tunnel vision." To use a more common use of the forbidden fruit metaphor, think of people who get drunk on their 21st birthday because they finally legally can, and the emphasis that people under 21 (the lower level provider) places on drinking because they know they shouldn't be.

Thoughts, critiques, criticisms?
 
I believe there is a mixture of the "forbidden fruit" and as well not understanding the "ins's & outs" of the procedures. Like a new toy, everyone wants to play. What most do not understand is skills is just one part..essential but tiny part of treatment regime.

Many of my EMT partners get confused because I do not use a set "cookie cutter" regime. Some patients get an IV some may not, some may get Solu-Medrol & while some may not... Why? Because each patient is an individual and as such I treat accordingly to that patients needs and illness and injury at that time. This confuses those that do not understand medicine, that not only is it a science it is also an art.... one practices. To fully understand and know the disease/injury process and to treat that accordingly, albeit it may be prophylactically or directly. Not a cookie cutter step process.. each getting the same thing.

What many do not understand that each procedure and for as that goes any treatment has potential risks and dangers. Even when we are treating accordingly, we are disrupting the homeostasis process. The reason why Paramedics are not routinely taught advanced procedures as central lines, pericardiocentesis, chest tube placement, and other advanced procedures is not that procedures themselves are difficult to perform but to be able fully understand and appreciate it as well as treat the risks often associated with it.

If one really wants to perform advanced procedures (IV's, ETI, etc) then they should have to be fully educated with the by products of it as well.

R/r 911
 
I think a lot of the arguing and backbiting that happens on threads like this have more to do with the way each side of the debate feels they are being perceived.

I would go out on a limb and say that most on this forum take what they do seriously. I would also say that it was a fair assumption that most of us are willing to increase our knowledge and skill sets. I don't think anyone in here would say that they know it all or that there isn't something they can learn or an area in which they can improve.

When we allow our personal experiences to color how we respond to some of these posts, and do so more from emotion, frustration, anger, jealousy, or pride, then things get ugly.

I see the situation from both sides, being married to a career FF/Paramedic and working as a volunteer EMT-B. When I hear comments about fire departments being detrimental to EMS, I have to weigh that against the way my husbands department conducts themselves, their training level, their professionalism, their dedication to their jobs and their desire to work within the EMS system. So, I tend to react emotionally first in defense of a group of individuals that I know to be sincere, dedicated professionals. My response is met with the frustration and anger created in a totally different system with a totally different set of experiences. Now, am I wrong because what I respond with is truth as I live it? No, and neither are you, the problem starts when we start making global extrapolations from our experiental data.

I understand that there are skills I should not have. I have been offered repeatedly the upgrade to EMT-I and have avoided taking the class because our low call volume will not allow me to practice the skills enough to maintain competency. So, why get a cert that I will not be able to do well? I gain the responsibility, but not the ability.

But, when those who have gone on beyond my level of skill start bashing (yes bashing, insulting, denigrating and devaluing) the role of BLS it annoys me no end. My annoyance is not based in a lack of appreciation for the virtues of ALS. Nor is it based in jealousy or your 'forbidden fruit' analogy. Because if I could earn my EMT-P and make as much money as I do in my day job, I would do it in a heart beat. But, the reality is that I can't. I'm not taking a year of my life off, going to school full time, to take a $10 an hour pay cut on the off chance that I could find a job within commuting distance of where I live. So, the fruit is not 'forbidden' to me, but simply not a fruit I choose to eat.

My area not only isn't ALS, but the closest district to us that used to provide us with ALS lost its certification and downgraded to a BLS system. So, comments about how EMS is moving forward towards an all ALS system is not applicable to my location. Again, comments made globally, words like 'all systems' the 'we must' Those comments tend to leave my situation and all the other small rural departments like mine (and I don't mean rural like 30,000 people, I mean rural like 900).

So, I do get a bit defensive, when I study, learn, teach, constantly work to improve my skills and pass that improvement on to everyone within my district. I have personally trained 3 paramedics and helped them to enter paramedic programs. I am very proud of their accomplishments and in no way feel them to be arrogant, elitist or any of the other insults about them passed around in this forum.

But, in my system, we work together. Fire/BLS/ALS are all parts of a team. I do not feel like I'm in the way when ALS arrives on scene. I feel my job is to give them a stable pt with at least one set of vitals, O2 on, the IV set up and ready for them to stick the pt. I can attach a 12 lead, ready an airway kit, I know when the medic is ready for his next tool and generally have it ready for him. I know the different medics. I know their personal styles with pts. I know which ones want me to set up the 12 lead and run them a strip and which ones perfer to do it themselves. I know who likes to use a towel under the arm of a pt before starting an IV and which one prefers one next to the arm on the gurney. A medic who enters my rig (which is how it is done here) will not have to wait, look or hesitate during pt. care.

I take pride in that. I take pride in my ability to help a call go smoothly. I take pride in my ability to always learn more about EMS. I have taken A&P, Medical Terminology, Micro-biology, and countless other classes. I have run thousands of calls. I have seen tons of pts. This is experience and deserves to be valued, not ranked as more or less than the experience that someone else has. It's not a freakin' competition!

I think the competitive will always respond to anything that says.. ALS is good, with 10 examples of crappy Paramedics they have worked with and 5 examples of ALS systems that suck. Or, the other side of the coin is those who will cite countless examples of how Firefighters suck as human beings and are basically a waste of skin, sucking money out of the EMS system. Or those who berate all EMT-Bs because the system they work in churns out undereducated, inexperienced children in uniforms without any concern about their ability to treat a patient.

But, if we can be mature, and stick to the issues, we can learn from each other. We can support each other and help our future patients get better care from whichever system they are in. We gain nothing from cutting each other down, or pouring gasoline onto the ALS/BLS wars. All we need to do is show each other some respect. If you can't respect the system that educates some EMTs, you can at least respect the decision of the individual to do something to help in emergencies instead of sitting at home by the TV watching re-runs of Emergency.

I know I have been guilty of responding too quickly to some posts. My dander gets up and I react emotionally. It happens, I'm human. But generally I try to find a middle ground rather than fill up my tin can of gasoline and wade in to the flames to kick butt and take names. Computer forums are full of the flaming and insulting posts, this one is less so than others, which is why I still post here. It's too easy to hit that Submit Reply button and read what you wrote later.

For the most part, I respect the intelligence, skills and dedication of pretty much everyone on this site. I simply expect the respect in return.
 
Excellent post Bossy!!

Unfortunately, not all can be as mature and professional as you. Although, you may not always agree with my view points, I respect your position and you.

R/r 911
 
To clear something up, I don't intend this to be a BLS v ALS bash thread. I'm a firm believer that stereotypes and cliches have at least some root in reality (or else they wouldn't exist). While people asking for changes in their SOP is one of them, the main issue I am trying to explore is the one involving advanced providers who get obsessed with advanced skills because all of a sudden they can (e.g. delaying transport on a trauma patient for an IV). Thus, it's more about paramedics than basics (and, to an extent, requiring B before P).
 
JPINFV said:
To clear something up, I don't intend this to be a BLS v ALS bash thread. I'm a firm believer that stereotypes and cliches have at least some root in reality (or else they wouldn't exist). While people asking for changes in their SOP is one of them, the main issue I am trying to explore is the one involving advanced providers who get obsessed with advanced skills because all of a sudden they can (e.g. delaying transport on a trauma patient for an IV). Thus, it's more about paramedics than basics (and, to an extent, requiring B before P).
Click to expand...

Of course a stereotype gets its start with a root in reality. You are driving down the road and an old man in a hat is driving 22 mph with his sealbelt hanging out and bouncing on the asphalt... ergo all old men in hats are bad drivers. The problem with that kernel of truth in a stereotype is that it eliminates the opportunity for the exception to the rule to be judged fairly on their own merits.

You should remember that it is just a kernel and the image is a stereotype, not a factual assessement of the data.

I think any new medic is going to be excited about their new found skills and less likely to not do something they can. Whether this is due to an obsession or just a matter of maturity within a job is up for discussion.

There is something we used to call 'new managers syndrome' it happened in the corporate world when a supervisor is elevated to management for the first time and immediately starts to micro-manage everyone under them. In many cases, those employees had a lot more experience with the company or the department than the new manager. But, there is a tendency to want to make ones mark. EMS is not exempt from any of the human frailties that affect other jobs. As long as we keep putting humans into those jobs, humanity will makes its presence known.

I think the key is to avoid making global judgements about "all new medics" or "all dinosaur basics". I read in another post about the glut of EMTs on the market. This is certainly not the case in my area. A local private ambulance company can't find enough to fill their shifts. We even had to cancel an EMT class because there weren't enough students to fill it.

Jung used a term 'synchronicity'. It speaks of how for example, when you learn a new word all of a sudden you are hearing it everywhere. Sometimes that is simply a matter of our attention being attuned to it. I think that is part of what happens with a new skill. You have the skill, those images and that information is in a new, exciting, important part of our memory. Of course we are going to view every patient with symptoms that fit that skill.
 
In my area of the country, I think there might be the possibility that there are too many medics. The sheer number of 911 calls that are BLS grossly outnumber the ones that require a medic - it's really mind-boggling as to the amount of 911 abuse around here; and every ALS truck has a medic. It would not surprise me if some of our ALS services went back to medics sprinting.
 
i agree completely with the whole forbidden fruit metaphor. however it all depends on how fast the person changes their level of training. By this I mean did the basic go straight to medic school or did they sit around for years and watch the medic do all sorts of "cool" things. in this line of work you want to be the best or the one that everyone counts on. so you want to look as professional in the field as you can. most interpret this is he/she who holds the most abilities to preform a task is inherently the best. i still use basic thinking before advance but i never waited for time between basic school and medic school.
 
Forbidden Fruit: any object of desire whose appeal is a direct result of the knowledge that it cannot or should not be obtained or something that someone may want but cannot have.

From that definition, I can see how it is rooted in the forbidden fruit mentality. Using myself as an example...I got done with basic class not feeling satisfied with the measly knowledge I got out of the class. Instead of being content at my level, I read books and watched the ALS providers more carefully as to the skills they performed. I equated great paramedics with the skills they did at that point...skills I could not perform (something I cannot have). I think some basic EMT's equate their greatness by the skills they can perform - the more they do, the better of a provider they are. It was only until AFTER I completed my paramedic class and had a few months of experience under my belt that I realized that the skills are the easy part, and are only a tiny part of what makes a good paramedic. I can't speak for all basic EMT's on here...only myself.
 
There's a phrase in the curriculum I teach for Wilderness First Aid that applies here. It's not so much knowing how to do something as it is knowing when you should and when you shouldn't do it.
 
We are all part of a system that is greater than ourselves. There is one common goal: The patient. From the bystanders to first responers to BLS to ILS to ALS to to nurses to ER drs To specialists to Rehab. I should have used the word "and", rather than "to" and would also have to include the fire fighters, rescue technicians and law enforcement. This is a profession whereby single entities can not take the credit for the outcome of the patient, weather it be posotive or negative. The age old saying of the chain is only as strong as the weakest link, has a strong influence in the EMS...

ALS should not be a forbidden fruit, but rather the tasty fruit that everyone wants. The problem is that tasty fruit take time to grow and mature, and in today's day and age, we often don't have the time, or are willing (or can't) to take risk from our comfort zone in order to futher ourselves in our profession. You are not the only that will benefit from this! There is a good chance that no matter what level you are currently practising at, you were where someone is now. Does this mean in anyway that they should now be slated? Exactly the opposite, one should do everything in your power to ensure that you treat other levels in the manner that you did not wanted to be treated but, were.
 
Last edited by a moderator:
A brand new medic I partnered with at my old company had me run a 12 lead on EVERYBODY. We were Interfacility only. But hey, why not? He taught me a lot. I enjoyed working with him.

Bossy, I have gained a lot of respect for you and insight from your post, and I must throughly agree there. I sincerely hope that the paramedics I work with view me much the way yours view you. I am always looking to learn, and I don't claim to much into knowing it all. Hardly. When we have competent and knowledge EMTs and Paramedics, our professionalism and patient care is vastly improved.
 
I like the "Carpenter" paradigm

When you buy a new hammer, everything needs a nail. ("Or a good bash"..Mycrofft's corollary).

EG: Two patients come into my medical hootch with heat exhaustion and some/same degree of dehydration. Neither is nauseous. Guy A goes to the left down MD Alley, Guy B goes down my alley.

Guy A gets a liter IV and is there for an hour being hovered over.

Guy B gets a canteen of half strength Gatorade (about a liter or a little more) and a snack from my breakfast MRE leftovers and is back on the line in thirty minutes.

VS at time of release are identical; and performance that PM and the next day are identical.

 
I'll chime in with saying this is a fluid profession and we are human beings and that is a good thing. Each of us is in the middle of a learning curve -- no matter WHAT we do. There are some times when we'll be rigid, other times loose, some times informed, other times ignorant. It's the getting from one to the other that's the challenge!

I went through the typical EMT, EMT-PARAMEDIC wanna be, PARAMEDIC GOD, PARAMEDIC worm, EMT-PARAMEDIC and all phases in-between stages, and they would have to include the Forbidden Fruit syndrome.

It's important to accept the way to become proficient is to be willing to try anything that is appropriate and then LEARN from it. Mistakes get made. Limit the consequences as best you can. An important component though is not to get stuck in any one phase trashing yourself because you're not at some other phase you think is better.

You are where you are and you'll get "there" when you get there.
 
Eek, why'd this get necro'd?

Anyway, my 0.02, is that you assess and treat the patient, with whatever is best indicated for relief, stabilization, slowdown of deterioration, and that whatever you have in your arsenal should be used as appropriate. Don't attempt to shoehorn a PT into a treatment regime based on what you'd like to do because you'd like to do it for any other reason than "best interests of patient". If positioning gives you a patent and stable airway, don't drop an OPA, let alone ET, and so on and so forth.
 
Roger the prior two replies!

I defibbed it because it sonded interesting.


CLEAR!
 
You must log in or register to reply here.
Back
Top