NYMedic828
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The practicality of EMT Basics as an emergecy responder
- Thread starter Veneficus
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I currently work in a B/P system and I can see the issues with the vast differences in scope between myself and the paramedic. My main issue is that there are many patients that deserve an ALS assessment before they could truly be downgraded to BLS, and once an ALS assessment is performed, there is really no reason for the medic not to take the call (since now they have to do a chart, assuming a 4 lead or a glucometer was done). You therefore have two issues, the first being that all I do is drive and carry stuff on important calls.
The second issue is that since we are dispatched either BLS (cold response) or ALS (hot response), the crew arrives on scene with preconceived notions of whether it will be a basic or advanced call. Therefore, there is some pressure not to be "that basic" who gets everything upgraded to ALS or "that medic" who turfs everything down.
Therefore you get situations where two patients with almost identical symptoms will get different levels of care, because one came in as ALS and one BLS. This is mostly an issue with lazy medics.
Now, its not an insurmountable obstacle, and I'm lucky enough to have a good working relationship with my medic partner, but the issue is there. If you ask me it's an issue that needs fixing, because there's no reason for the patient not to have the best care for their condition, whether it be BLS or ALS. Many medics have stories about pts who they checked just to take the work off their EMT partner who had been providing all day, only to find that this "BLS" pt was having an MI or something similar. We shouldn't be finding MIs based off only dispatch information and random chance.
If I had my AEMT (PA doesn't have ILS...AEMT is supposed to be coming), then any "rule out" assessments such as a 4-lead could be performed by me, allowing a transport decision to be made without making everything ALS, which would certainly lessen the above issue.
I'm also a fan of a dual response system with medic chase cars, but again, this requires good assessment skills from BLS providers, which I can certainly tell you I wasn't taught in class.
The second issue is that since we are dispatched either BLS (cold response) or ALS (hot response), the crew arrives on scene with preconceived notions of whether it will be a basic or advanced call. Therefore, there is some pressure not to be "that basic" who gets everything upgraded to ALS or "that medic" who turfs everything down.
Therefore you get situations where two patients with almost identical symptoms will get different levels of care, because one came in as ALS and one BLS. This is mostly an issue with lazy medics.
Now, its not an insurmountable obstacle, and I'm lucky enough to have a good working relationship with my medic partner, but the issue is there. If you ask me it's an issue that needs fixing, because there's no reason for the patient not to have the best care for their condition, whether it be BLS or ALS. Many medics have stories about pts who they checked just to take the work off their EMT partner who had been providing all day, only to find that this "BLS" pt was having an MI or something similar. We shouldn't be finding MIs based off only dispatch information and random chance.
If I had my AEMT (PA doesn't have ILS...AEMT is supposed to be coming), then any "rule out" assessments such as a 4-lead could be performed by me, allowing a transport decision to be made without making everything ALS, which would certainly lessen the above issue.
I'm also a fan of a dual response system with medic chase cars, but again, this requires good assessment skills from BLS providers, which I can certainly tell you I wasn't taught in class.
Brandon O
Puzzled by facies
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Not sure what a "4-lead" (meaning a four-electrode ECG) would help you rule out, or for that matter, what it would help you rule in that you could treat at that level?
12-lead, my bad.
As for treatment, my point would be that if the second provider had the ability to interpret ECG readings, that would remove the institutional pressure not to make calls ALS for assessment only. If the basic provider could look at the 12 lead and say "nope, no problems", he can also write the chart, handle care, etc. If he looks and sees trouble, then the medic can upgrade.
The way it works now is that since every ECG is an ALS call by definition, there are patients that do not receive a full assessment because of the idea of "if it's dispatched BLS, it's BLS", and there are basics and medics who subscribe to this (wrong) idea. Like I said above, if my unit is sent to an "ALS sick person", they will get an ALS assessment. If it's a "BLS sick person", its likely they will get a BLS assessment. This is the same even if the patient has identical symptoms (assuming those symptoms aren't automatically ALS in nature). Therefore you get patients who slip through the cracks since they present with non obvious symptoms.
As for treatment, my point would be that if the second provider had the ability to interpret ECG readings, that would remove the institutional pressure not to make calls ALS for assessment only. If the basic provider could look at the 12 lead and say "nope, no problems", he can also write the chart, handle care, etc. If he looks and sees trouble, then the medic can upgrade.
The way it works now is that since every ECG is an ALS call by definition, there are patients that do not receive a full assessment because of the idea of "if it's dispatched BLS, it's BLS", and there are basics and medics who subscribe to this (wrong) idea. Like I said above, if my unit is sent to an "ALS sick person", they will get an ALS assessment. If it's a "BLS sick person", its likely they will get a BLS assessment. This is the same even if the patient has identical symptoms (assuming those symptoms aren't automatically ALS in nature). Therefore you get patients who slip through the cracks since they present with non obvious symptoms.
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Brandon O
Puzzled by facies
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Yes, that would be nice, although if you're going to be interpreting it on your own (not sure your scope over there) that's quite another can of worms.
Probably more than two-thirds of the time I look for ALS it's merely to get a 12-lead done and rule out ACS, but most of the medics in my current system aren't comfortable kicking down the call once they've put electrodes on a chest, so they end up taking 'em anyway even when it's negative.
Brandon O
Puzzled by facies
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Well, the reason would be to free up the ALS unit, just like always. The fact that they've already spent some time here doesn't change that.
The main reason medics like to stay on these calls is liability; they don't want to be the guy who sent away the big one, especially when they're not completely confident in their ability to rule it out using the ECG. (And of course, with some equivocal patients they shouldn't be doing so -- but there are plenty of generally well folks with a minor complaint who just need a quick screen to make sure they're not trying to sneak by a gigantor STEMI with an atypical presentation.
Horses for courses, I suppose.
I feel with fly cars the issue is lessened. If you make the response in a chase car, you have paperwork to do, period. Therefore, assessments are no skin off your back.
In a truck with a medic and a basic, there can be pressure for a call that appears to be BLS to stay that way, because a lazy medic won't want to do a full assessment since that means he suddenly has a chart to do.
Is that practice acceptable? No. But it happens.
In a truck with a medic and a basic, there can be pressure for a call that appears to be BLS to stay that way, because a lazy medic won't want to do a full assessment since that means he suddenly has a chart to do.
Is that practice acceptable? No. But it happens.
TransportJockey
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I am not a fan of chase cars due to the simple fact that with a 3.5k sq mi service area, most of it very rural, they are not practical. And that's where it becomes more economical to make each truck at least ILS level, if not ALS level.
RocketMedic
Californian, Lost in Texas
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Definitely this, but its not insurmountable. AMR Otero's supervisors run an ALS fly car.
TransportJockey
Forum Chief
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That they do, but Otero, in the scheme of things in NM, has a relatively high population density. It's not the extreme ruralness of areas like Pecos TX (which oh dear god it sucked)
Bullets
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Unfortunately the science out there is changing the way we view our advanced practitioners. All these ACLS drugs may not actually do anything and might just harm patients. Medics can't tube reliably, stroke patients really need someone to pick them up and go to the hospital.
Unless there is a change in the attitude of in medics around here, Emts will remain. If I called ALS for pain management I would get laughed at and they would leave. Very rarely do they release to basics even if all they do is the stare of life. And when I do ask for them to do an assessment on patient who isn't visibly circling the drain I usually get an attitude. And this its true for multiple ALS agencies
Unless there is a change in the attitude of in medics around here, Emts will remain. If I called ALS for pain management I would get laughed at and they would leave. Very rarely do they release to basics even if all they do is the stare of life. And when I do ask for them to do an assessment on patient who isn't visibly circling the drain I usually get an attitude. And this its true for multiple ALS agencies
DrParasite
The fire extinguisher is not just for show
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Sounds like you have worked with the JC medics.
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If ALS was dispatched on the initial dispatch do you think the same patient would get pain medication? If not, why not?
Bullets
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No, i doubt they would get pain medication
A.) unless its a serious trauma/MVC Medics arent routinely dispatched for most non-medical calls if there isnt a report of LOC.
B.) if they are sent they usually are focused on other things besides pain management. BLS is doing the wound care and bandaging, while ALS usually secures two lines and the airway when needed
I can think of only a few times a patient has received pain meds and this is having experience with many different ALS agencies
RocketMedic
Californian, Lost in Texas
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It sounds like the paramedics you work with totally suck, dude. Pain management is an important part of patient care, and although there are circumstances where we cannot manage pain (ie pregnant female with abdominal pain) per protocol, there are plenty of patients where we can. It's both the medically and ethically right thing to do.
RocketMedic
Californian, Lost in Texas
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No disagreement, but that predicates additional training, resources and medical direction that most American paramedics don't have in-hand. That Bullet's paramedics are apparently not even managing isolated, non-complicated pain implies either apathy/incompetence, restrictive medical direction, or reporter bias.
Jersey, in other words.
