L.A. County EMS Laws

[triemal04]

Daedalus-

Actually I don't really disagree that EMS in Southern Cali is screwed up. (perhaps you should re-read the post if you didn't get that). What I disagree with, and was pointing out was that the examples and situations you used to try to get that point across were, for the most part, not valid. Nobody is trying to to "disprove" anything you may have seen; but anecdotal stories from someone with your bias (even if it's a valid bias in this case) doesn't mean much. An arguement doesn't really mean much if the claims that are made don't add up. Clear?

venty....why do you do this to yourself? Do you actually read posts anymore, or just hit the reply button and type whatever random thought is going through your head?

 

[thegreypilgrim]

turns out I wasn't.
I'll leave it to the readers to see if the conclusions reached have any bearing on the idea that having Paramedics that can do more and more procedures in the field, with or without an MD or an RN's supervision is a good idea or not.

John, I seriously doubt anyone is suggesting that Paramedics' scope of practice should just be arbitrarily increased to allow them to do all sorts of cool crap in the field for no reason. You're creating a straw man. If you just stood back and didn't consider your opponents' posts in isolation you'd see the larger picture. Virtually everyone challenging you here is one who advocates expansion of paramedic education first, and therefore increasing their general scope of practice and clinical independence. No one is advocating we always do all our ALS interventions on every patient we ever see because that's what we do because we're ALS and so on. You also keep bringing up the OPALS study as some sort of bizarre defense of the restricted scope for LA County EMS. What precisely is your point here? You think the LA County Medical Director read OPALS and said, "Holy *beep* I gotta get my medics in line with current research!" and that's why LA has such a crappy scope? Since when did OPALS become the gold standard for prehospital trauma management anyway? As far as I know most authorities in the U.S. are still trying to figure out how to interpret it and even apply it to the American system. Nor am I aware of organizations like the AMA or ACEP or ACS suddenly revising their standards to make them in accordance with OPALS. Yeah, we all get that penetrating trauma patients fair worse with fluid resuscitation and spending time on scene to intubate them if transport times are short. As far as I can tell no one's trying to challenge that, and this is just so off course from the initial discussion that I don't even understand how we got here.

Daedalus and myself have just offered up our own observations and opinions on the nature of LA EMS after having spent considerable time working in that system. Nothing further has been suggested. Yet, somehow, these observations have been interpreted as an attempt to "prove" something (that's really the wrong word to use in this context too, let's not allow ourselves to be bewitched by language games). I don't really see what your motivation is, nor can I understand how you could have worked in this system as an EMT and think it's "fine" or otherwise no worse off than other systems.

 

[JPINFV]

As someone else wrote, just for clarification, I don't believe, think, or know that what we call BLS is the same as what our brothers and sisters in Kanuckistan call BLS. I also never wrote, stated, claimed, exclaimed, pontificated, or espoused that belief. As I've written before, if you can find a post in which I did so, please post it.

My comments about the study which did not take place in or around Pomona or even Ontario, California were very specific, I asked for people interested to read the summary of the OPALS that was written by the Medical Director of Ventura/Santa Barbara Counties and that was published in EMS Responder magazine, specifically the fifth and seventh paragraphs of the writers conclusions. If one were to do that, one would find that the writer is not comparing Canadian and U.S. BLS practices nor is it comparing Canadian and U.S. BLS practices vs ALS practices.

First off, thank you so much for providing a reference. At the very least, a link would have been appropriate, however, here you go.

http://www.emsresponder.com/print/EMS-Magazine/Literature-Review--Advanced-Life-Support-for-Major-Trauma-Patients/1$8060

To take OPALS and apply it to US is saying that their BLS and our BLS is the same. Period. There is no discussing this fact. To take a study that, in the words of your article, "compared the outcomes of patients for three years in BLS systems and then for three years after introducing paramedics in ALS systems," and trying to advocate BLS treatments in the US is simply absurd without clarifying and discussing the differences between an EMT-B in the US and a primary care paramedic in Ontario (Canada) makes a critical error in analyzing this study.

Furthermore, you, at no time in the post where you brought this up, specified "trauma." This brings up a few major points. First, I can find articles that showed that it is safer for trauma patients to be transported by private vehicle than to wait for an ambulance. Should we stop sending ambulances to traumas since ambulances are associated with worse outcomes when compared to 'home boy ambulance service?' Second, even your article admits that "For minorly to moderately injured patients, an IV with analgesia is very appropriate." So, what should we do? Send EMT-Bs only to traumas and have them call for paramedics if they aren't going to die in the next 3 minutes?

Third (and this get's it's own segment), OPALS looks at more than cardiac arrest and trauma. Here's a gem at the end of one part of OPALS* that ties this entire thing together. "A program to administer medications for symptom relief (nebulized salbutamol and sublingual nitroglycerin) was introduced toward the end of the first phase of this study. Although this program was not specifically related to advanced life support, it may have been a factor that influenced the benefit in the second phase of the study." So the introduction of symptom relief might have been a factor, but looky here. It's salbutamol (albuterol) and nitroglycerin. Gee. Those aren't BLS interventions in the US (especially California), but they aren't considered ALS in Canada, but those are considered an important set of treatment interventions.

Does ALS make a difference in Ontario (Canada)? Well, it depends on the complaint. However, applying OPALS to the US would mean comparing paramedics to PAs trained in emergency medicine because Canada calls our paramedics "BLS" and our basics "first responders."


*Since I'm actually trying to make a consistant discussion, I'll actually provide a reference and link.

Stiell IG, Spaite DW, Field B, et al. Advanced Life Support for Out-of-Hospital Respiratory Distress. N Engl J Med. 2007. 356;21
http://content.nejm.org/cgi/reprint/356/21/2156.pdf

 

[VentMedic]

Now ask me if I care what you believe?

Just don't it via private messages, I've got enough of those from you already.

John E

You sent the first PM and you continue with the PMs. Enough already. You are only showing you don't understand anything JPINFV, daedalus or anyone has tried to explain to you.

You must read a study before you spout off stuff about it.
You must understand the difference between Ontario, Canada and Ontario, Calfornia.
You must understand that the OPALS are NOT referring to the 120 hour EMT-Basic in their "BLS" study.

However, I will repeat again, you MUST READ a study and understand it first.

 

[fortsmithman]

P.S. The people who live and work in Ontario, California might take exception to your statement that Ontario is in Canada...
John E

I'm Canadian and fyi the Province of Ontario is one of our more heavier populated provinces as well as being the province that the national capital Ottawa is located in.

 

[John E]

I take your point...

But as I've written before, I'm done with this thread. And this time I mean it.

If people are going to accuse me of not knowing where Canada is, I'm just not going to play.


John E


P.S. I do want to apologize here publicly to daedalus, I used some pretty harsh words in my earlier posts to you and I shouldn't have, for that I'm sorry.

 

[John E]

I should have been more clear...

Ontario is not ONLY located in Canada.

Apologies to my brothers and sisters in the land of poutine and Leonard Cohen, long may it wave...

John E

P.S. J, can I call you J? I only referred to 2 paragraphs of the conclusion which you seem to have either overlooked or skipped. They helped prove the point which I was making. Which was again that simply increasing scopes of practice and allowing Paramedics to do more without direct supervision is not a guarantee of better patient care or of increased survival rates. Since I didn't cite the entire study I can't speak to it's accuracy. One would hope that the Medical Director of Ventura/Santa Barbara counties would when he wrote:

" There is great value in the prehospital treatment of trauma patients. Accurate assessment and triage, careful extrication, airway positioning with suctioning, spinal immobilization, assisted ventilation, bleeding control, splinting and expeditious transport to the most appropriate hospital are all important measures to reduce mortality and disability. For minorly to moderately injured patients, an IV with analgesia is very appropriate. However, for critical trauma patients, the ALS procedures of endotracheal intubation and intravenous fluids do not appear to provide benefit, and the best prehospital treatment appears to be bag-valve mask ventilation and BLS measures as needed, with prompt transportation to the closest appropriate facility."

 

[daedalus]

Daedalus-

Actually I don't really disagree that EMS in Southern Cali is screwed up. (perhaps you should re-read the post if you didn't get that). What I disagree with, and was pointing out was that the examples and situations you used to try to get that point across were, for the most part, not valid. Nobody is trying to to "disprove" anything you may have seen; but anecdotal stories from someone with your bias (even if it's a valid bias in this case) doesn't mean much. An arguement doesn't really mean much if the claims that are made don't add up. Clear?

venty....why do you do this to yourself? Do you actually read posts anymore, or just hit the reply button and type whatever random thought is going through your head?

I never implied that I had proof or that my experiences were substitutes for proof. In fact, I believe I said that I would not trust EMS folks in LA with my dog's life. That is a far cry from saying "I can prove that prehospital care in LA sucks". However, point taken.

I stand by my statements. I am in firm belief that the prehospital care in Los Angeles sucks major horse's butt. This is formed from my experiences. I only offer my opinion as the sum of my experience and nothing else. You may decide to disagree with me, however, before accusing me of being wrong I suggest you ride out a few shifts down here.

John E, I am perplexed. You have insulted people that I am quite fond of here just because they called you out on your posts. Like greypilgrem said, none of the people you are arguing with are advocating increases in the amount of skills paramedics can do. In fact, VentMedic, JPINFV, and myself all have called out paramedics and EMTs who think in the "skills" mentality. You have criticized increasing paramedic education in another thread, and than criticized ALS level interventions in this thread. Taken together, I can only assume you think that paramedics should not increase educational standards and should not do ALS level care because it results in poor outcomes (our logic). Is this a pass at paramedics in general?

I do not mind people disagreeing with me, I just do not understand your stances on issues facing EMS and what experiences lead you to say the things you have said.

 

[daedalus]

P.S. J, can I call you J? I only referred to 2 paragraphs of the conclusion which you seem to have either overlooked or skipped. They helped prove the point which I was making. Which was again that simply increasing scopes of practice and allowing Paramedics to do more without direct supervision is not a guarantee of better patient care or of increased survival rates. Since I didn't cite the entire study I can't speak to it's accuracy. One would hope that the Medical Director of Ventura/Santa Barbara counties would when he wrote:

" There is great value in the prehospital treatment of trauma patients. Accurate assessment and triage, careful extrication, airway positioning with suctioning, spinal immobilization, assisted ventilation, bleeding control, splinting and expeditious transport to the most appropriate hospital are all important measures to reduce mortality and disability. For minorly to moderately injured patients, an IV with analgesia is very appropriate. However, for critical trauma patients, the ALS procedures of endotracheal intubation and intravenous fluids do not appear to provide benefit, and the best prehospital treatment appears to be bag-valve mask ventilation and BLS measures as needed, with prompt transportation to the closest appropriate facility."

Again, this is for trauma only. Dr. Salvucci has also said in reference to the OPALS study:

The addition of a specific regimen of out-of-hospital advanced life support interventions to an existing EMS system that provides basic life support was associated with a decrease in the rate of death of 1.9 percentage points among patients with respiratory distress

"ALS" level care is superior to BLS level care for medical calls. However, I also argue that ALS level care is superior to BLS care in trauma as well. We have evolved our management of trauma patients in the field thanks to (unfortunately) the wars in Iraq and Afghanistan. We have learned a lot about fluid resuscitation and permissive hypotension. We have learned to limit time on scene, move intubation down on our priorities, use capnograpghy as needed to confirm placement, and to start IVs en route as opposed to on scene. Should you doubt this new line of thinking, check the latest ITLS standards. Paramedics also have a much improved understanding of trauma, anatomy, and the physiology of shock. They should be able to better care for trauma patients than EMTs. Paramedics can also provide "BLS" interventions. Both BLS and ALS are medical care and paramedics are in a better position to provide medical care as they have practiced it more than an EMT in school, and have a greater understanding of the human body and pathology.

 

[JPINFV]

Ontario is not ONLY located in Canada.

Apologies to my brothers and sisters in the land of poutine and Leonard Cohen, long may it wave...

John E

P.S. J, can I call you J? I only referred to 2 paragraphs of the conclusion which you seem to have either overlooked or skipped. They helped prove the point which I was making. Which was again that simply increasing scopes of practice and allowing Paramedics to do more without direct supervision is not a guarantee of better patient care or of increased survival rates. Since I didn't cite the entire study I can't speak to it's accuracy. One would hope that the Medical Director of Ventura/Santa Barbara counties would when he wrote:

" There is great value in the prehospital treatment of trauma patients. Accurate assessment and triage, careful extrication, airway positioning with suctioning, spinal immobilization, assisted ventilation, bleeding control, splinting and expeditious transport to the most appropriate hospital are all important measures to reduce mortality and disability. For minorly to moderately injured patients, an IV with analgesia is very appropriate. However, for critical trauma patients, the ALS procedures of endotracheal intubation and intravenous fluids do not appear to provide benefit, and the best prehospital treatment appears to be bag-valve mask ventilation and BLS measures as needed, with prompt transportation to the closest appropriate facility."

Apparently you didn't read my post because I quoted a section of that exact paragraph and have underlined it here. Should we stop sending paramedics to traumas until it's determined that the patient isn't going to die immediately? Furthermore, there's other things to consider than mortality. Denying paramedics (which, with the proper training wouldn't be ****ing around on scene anyways) to patients also denies pain control and other measures. Can I volunteer you to be the patient who gets denied pain control since "BLS" is 'better' for traumas (note: not specifying severity, just trauma in general).

Hell, I'll take this a step further. Transport by POV has at least one study that shows better outcomes than ambulance transport Since ransporting by POV has a lower mortality rate than ambulance transport, can we stop sending ambulances to car accidents and shootings?

"CONCLUSIONS: Patients with severe trauma transported by private means in this setting have better survival than those transported via the EMS system."
-Demetriades D, et al. Paramedic vs private transportation of trauma patients. Effect on outcome. Arch Surg. 1996 Feb;131(2):133-8.
http://www.ncbi.nlm.nih.gov/pubmed/8611068

 

[atropine]

I never implied that I had proof or that my experiences were substitutes for proof. In fact, I believe I said that I would not trust EMS folks in LA with my dog's life. That is a far cry from saying "I can prove that prehospital care in LA sucks". However, point taken.

I stand by my statements. I am in firm belief that the prehospital care in Los Angeles sucks major horse's butt. This is formed from my experiences. I only offer my opinion as the sum of my experience and nothing else. You may decide to disagree with me, however, before accusing me of being wrong I suggest you ride out a few shifts down here.

John E, I am perplexed. You have insulted people that I am quite fond of here just because they called you out on your posts. Like greypilgrem said, none of the people you are arguing with are advocating increases in the amount of skills paramedics can do. In fact, VentMedic, JPINFV, and myself all have called out paramedics and EMTs who think in the "skills" mentality. You have criticized increasing paramedic education in another thread, and than criticized ALS level interventions in this thread. Taken together, I can only assume you think that paramedics should not increase educational standards and should not do ALS level care because it results in poor outcomes (our logic). Is this a pass at paramedics in general?

I do not mind people disagreeing with me, I just do not understand your stances on issues facing EMS and what experiences lead you to say the things you have said.

You don't have any LA experience in LA buddy, unless you have to wake up in the mornig give drills on equipment study your *** off for your probationary test, and workon the RA, or squad then you can rant about all your experience until then your are just a hater for what ever reason, my point to all this is that people talk crap about this system and don't work in it. Even if your a private medic in the LA ciounty area your not part of any of the 911 system, so I don't get how your points can even be valid, and yes I am all for change but the MD's with the higher uo education feel that nothing is broken so why fight it, can't we just all get along with our cool jobs, great bennies, and suv's.^_^

 

[daedalus]

You don't have any LA experience in LA buddy, unless you have to wake up in the mornig give drills on equipment study your *** off for your probationary test, and workon the RA, or squad then you can rant about all your experience until then your are just a hater for what ever reason, my point to all this is that people talk crap about this system and don't work in it. Even if your a private medic in the LA ciounty area your not part of any of the 911 system, so I don't get how your points can even be valid, and yes I am all for change but the MD's with the higher uo education feel that nothing is broken so why fight it, can't we just all get along with our cool jobs, great bennies, and suv's.^_^

This is laughable. I was a EMT at a company that provided 911 transport to LAcoFD. I worked with the paramedics. I quit that job and went to an IFT company in LA while I went to school. I then quit that job, and am at my new one somewhere else out of the county.

I also do not need to do drills in the morning to know what I am talking about, since FD drills have nothing to do with medicine. Perhaps I should have you take organic chemistry before getting into a debate with me?

 

[fortsmithman]

Before I joined my town's ambulance service I thought that fire and EMS went together. After joining the service and reading posts from EMS personnel in govt third service agencies and private service as well as fire I've come to the conclusion that EMS should be a separate service. The posts that influenced my views came from the fire medics on this forum. If we were to be merged with another public safety agency then it would have to be the police service.

 

[atropine]

This is laughable. I was a EMT at a company that provided 911 transport to LAcoFD. I worked with the paramedics. I quit that job and went to an IFT company in LA while I went to school. I then quit that job, and am at my new one somewhere else out of the county.

I also do not need to do drills in the morning to know what I am talking about, since FD drills have nothing to do with medicine. Perhaps I should have you take organic chemistry before getting into a debate with me?

about your 911 transport that really doesn't count now does it, I wouldn't trust the privates to even take a B/P for me, and drill have everything to do with medicine and more again unless your there you can't talk. I have given drill on meds, MCI's IV cathiters, and much more along with the suppression stuff. I not trying to ruffle feathers here, but dual role really deserves all that we get, for obtaining the knowledge we have to use and do on a daily basis.

 

[mycrofft]

"Oh, YEAH!??"

You guys still at it?