The practicality of EMT Basics as an emergecy responder

[Veneficus]

We arrive, and make our Sick/Not sick call based on our protocols, MOI, NOI etc. This way, BLS providers get very good at handling "not sick" patients, and ALS only handle "sick" patients.

I do not think this is an accurate assessment.

I don't think Basics have any idea what is sick or not sick unless it is so obvious anyone could figure it out or they had a specific experience in that particular presentation before.

I think triage based on things like MOI are extremely unreliable and cause more than a reasonable level of over-triage compared to what can be attained with current ALS providers.

Over-triage means wasted resources based on "just in case."

Consider what constitutes an emergency patient?

a. a patient who has an acute life threatening condition requiring immediate intervention.

b. a patient who if doesn't receive prompt intervention will deteriorate to a.

Undoubtably Basics have the ability to make a difference in a.

But b. is becomming more common in western society.

 

[Schroeder]

This may be true. I don't claim to have lots of experience telling me otherwise. This is, however, what I was trained to do. And of what I have seen, It works well.

You could give basics some benefit of the doubt when determining "sick" patients however. At least in my protocols, I have very clearly outlined ALS indicators which have been drilled into me from day one.

 

[Veneficus]

You could give basics some benefit of the doubt when determining "sick" patients however. At least in my protocols, I have very clearly outlined ALS indicators which have been drilled into me from day one.

I understand your position to be: you know what sick is because if you don't know you call ALS, thus categorizing the patient as "sick?"

 

[Schroeder]

Just to make sure I'm being clear:
In my system, "Sick" is defined as any patient who needs ALS. Not sick is any patient that can be handled by BLS.

Maybe I'm thinking of something different that what you are referring to?

 

[Jambi]

Just to make sure I'm being clear:
In my system, "Sick" is defined as any patient who needs ALS. Not sick is any patient that can be handled by BLS.

Maybe I'm thinking of something different that what you are referring to?

The point is that your average EMT-like-mammal does not posses the education, training, experience, or ability to accurately determine sick or not sick outside of those obvious conditions that anyone can recognize.

 

[Veneficus]

Just to make sure I'm being clear:
In my system, "Sick" is defined as any patient who needs ALS. Not sick is any patient that can be handled by BLS.

Maybe I'm thinking of something different that what you are referring to?

I used the common medical definition of sick. Defined above.

 

[Schroeder]

Alright then. You'll have to excuse my persistence. My point of view is that of a Basic, so the information I get is interpreted as such.

What kinds of factors are you referring to that Basics couldn't catch?

 

[nocoderob]

What do you see that is odd about it?

Unless there are certain indicators in the 911 call, BLS is dispatched. We arrive, and make our Sick/Not sick call based on our protocols, MOI, NOI etc. This way, BLS providers get very good at handling "not sick" patients, and ALS only handle "sick" patients. We have adequate tools to handle sick patients until Medics arrive.

The resources are allocated appropriately, and you usually get a response from someone who has lots of experience doing what they do.

Maybe I'm misunderstanding what you're asking?

Let me be more clear. If ALS shows up and the "arm cramp" complaint actually turns out to be cardiac, the medics are there and do their thing. If BLS was dispatched, the pt now has to wait longer for the ALS rig to arrive. The answer from many basics will then be just to haul azz to the ED and not wait for ALS. I see this as a disservice to the pt.

 

[Schroeder]

Our protocols have us wait or intercept with Medics. Since we're in an urban center, the wait time in only a few minutes.

 

[nocoderob]

Our protocols have us wait or intercept with Medics. Since we're in an urban center, the wait time in only a few minutes.

The point I am trying to make is why should the pt have to wait longer? This job is filled with "minutes." From response times, scene times, 911 to balloon times, and on and on. To say "only a few minutes more" is really a cop out by the system.

 

[Veneficus]

The point I am trying to make is why should the pt have to wait longer? This job is filled with "minutes." From response times, scene times, 911 to balloon times, and on and on. To say "only a few minutes more" is really a cop out by the system.

How often do minutes really make a difference?

 

[nocoderob]

How often do minutes really make a difference?

Depends on how many minutes you are talking. I guess I wouldn't be happy to have a family member in a potentially lethal rythym sitting with the emt's
while waiting for als that, in my opinion of course, should have been dispatched initially.

 

[Veneficus]

Depends on how many minutes you are talking. I guess I wouldn't be happy to have a family member in a potentially lethal rythym sitting with the emt's
while waiting for als that, in my opinion of course, should have been dispatched initially.

How would you know what the rythym is?

 

[nocoderob]

How would you know what the rythym is?

Thats my point. The emt's wouldn't know.

 

[mycrofft]

We ran a tired (make that "tiered") system of sorts at my work. RN's did sick call, and if what we saw fell into parameters needing emergency care or to see the MD (now, soon, or later as scheduled), we did it; otherwise, we had "standardized procedures" (an inch and a half thick).

BUT we were not EMT's. Good part: we (putatively) had better education as to diagnostics of simple primary care, emergencies, and malingering. Bad part: since they had little to no practical emergency education, many of my cohorts just turfed everything except the easiest calls to the MD. Occasionally they failed to and then I had to run emergently on them.

I think there are some very basic diagnostics EMT-B ought to be able to do (fingerstick glucometry, pulse oximetry, otoscopy of the external nares and the ear, taking a temperature orally or rectally) which are not infrequently taught to family members, and could provide more info for triage. I now, this is against my general stance (stop inflating ratings), but these are so simple.

 

[mycrofft]

This thread makes me want more than ever to have a means of separating discussions by geopolitics (urban/suburban, rural, remote (frontier, oil rigs, expeditions, New Zealand extreme eco ironman triathlons, etc),

 

[Bullets]

This thread makes me want more than ever to have a means of separating discussions by geopolitics (urban/suburban, rural, remote (frontier, oil rigs, expeditions, New Zealand extreme eco ironman triathlons, etc),

Absolutley, because we have the discussions and they always turn into "Well in Big City EMS we do it this way" and "In Ruralburg EMS we do it this way" and "Middle of Antartica EMS we do things like this"

and we realize that what works for a high populated state like NJ doesnt for Montana or the Dakotas.

This is the problem that currently exists, if a patient says "I wanna go" then we go and we cant refuse the transport. And i love the idea of a community paramedicine but so far we havent seen American medics do this with any form of consistency.

Whats the science and studies so far? More medics = bad medics. Response time doesnt matter, ACLS might just be junk, oxygen has been over applied, we dont treat pain appropriatley

The system needs to be stripped down and reevaluated. What works? Compressions, electricity, direct pressure, D50 ect... What doesnt work? Throw it out! The decide if we want a two tier or one tier system and break the skills up accordingly.

And then use the choppers for something that actually matter, put Docs in them and fly em to scenes, instead of just generating a big bill and letting people yell "SEND THE BIRD" on the radio

 

[leoemt]

While engaged in the endless threads here about EMTBs expanded scopes, usefulness, demands, etc, and having more time on my hands lately, I was wondering...

Is the service provided by the EMTB level really useful? (not to be confused with service provided by people who are EMTBs as like all providers there are good ones and bad ones)

In standard dinosaur manner, when I became an EMT-B, it was likely that was all anyone who called 911 was getting. We were the primary responders as well as the only prehospital person anyone was likely to see. From Soup to nuts, we ran every aspect of the call.

It seemed to work really well. (For what we knew at the time)

As paramedics became more popular in the area, the EMT was largely relegated to carrying equipment, driving, and performing ordered tasks in the official role as "a borrowed servant."

In this role, all of the benefits of being an EMT before becomming a medic are largely lost.

As our knowledge and technology advanced, the "basic" levels of assessment and intervention have largely become obsolete.

Yet the curriculum still revolves around EMTs being the sole responder in charge. (No doubt in many places they are still)

But for all of the advancement in scope and education, the level of assessment is still woefully under what is required. Evidenced by the stressing of calling for ALS throughout the educational process.

It is generally accepted in medicine, including prehospital, patients should be treated for pain.

It is a medical error to over-treat patients. (though we must admit to accepting some level of over treatment in any acute environment.)

But what do basics bring to the table?

CPR and an AED?
We know that early CPR and defib are effective treatments. But we also know that it is the bystander who will be able to effect this in time. CPR and an AED are useless after 8 minutes of nothing.

Assisting with meds?
Anyone can assist with meds. It doesn't even take a responder.

A handful of meds already carried and utilized by more advanced providers?

A spint?

A backboard?

I think it is obvious that many basics realize or want more treatments to be more effective. From narcan to pain medication.

There are dozens of add on certs in various states to amplify the value of the Basic EMT.

Nothing taught in EMT class is really useful for IFT, where most EMT Basics work.

In an ALS system, the Basic is far more useful as the tech for the medic than an independant provider.

Perhaps we should just come to terms that with the levels of medical care and technology expected today, the solution is not to "upskill" or "up educate" the EMT Basic.

The solution may be to just get rid of it?

The recently revamped AEMT is basically the minimum skill set and knowledge base that incorperates all of the "upskills" and add on meds Basics seem to think they need.

Should AEMT be the minimum to work on a EMS transport unit?

With the Basic level being the minimum level of "first responder."

Even at 150 hours for EMT, it is reasonable to do away with the first responder level entirely.

I would say it depends on area and what is expected. Here in my area, I don't see Medics performing "Basic" Skills. The EMT's thump the chest during CPR, perform extrication and stabilization. Medics busy themselves with the ALS stuff. Drugs, advanced airways, 12 leads, etc.

It is also dependent on local protocols. In my county I have to obtain my IV and Combitube endorsements as a Basic.

Lets face it, Paramedics have a tremendous wealth of knowledge and abilities and are a vital role to emergency service. Despite that, Basic skills save lives. Drugs, and advanced airways, etc. can have a significant impact on patient outcomes - but without good basic skills its all a moot point. It is easier and cheaper to train a basic to perform basic skills than it is to train everyone to the level of ALS.

Basic's will never go away. Just like the First Responder has never gone away (though it is not always recognized by every area).

My personal opinion is we should have a Medic - Basic and a Medic - Advanced (the public refers to us as Medics anyways, make it easy for them). The basic should have the training of what is now an Advanced EMT and the Advanced should have the training of what is now the Paramedic and maybe even then some. Maybe closer to an RN.

I am sure in other areas Paramedics do more basic and advanced skills. In my area it would be a rare event to see Paramedics doing BLS skills but that is just how were set up.

 

[DrParasite]

Whats the science and studies so far? More medics = bad medics. Response time doesnt matter, ACLS might just be junk, oxygen has been over applied, we dont treat pain appropriatley

The system needs to be stripped down and reevaluated. What works? Compressions, electricity, direct pressure, D50 ect... What doesnt work? Throw it out! The decide if we want a two tier or one tier system and break the skills up accordingly.

Well said.

 

[Brandon O]

I find it peculiar that you'd say, Vene: "As our knowledge and technology advanced, the 'basic' levels of assessment and intervention have largely become obsolete" -- given your belief in and advocacy for the traditional clinical H&P.

Which, strictly speaking, is within the BLS scope of practice.