Why aren't all EMTs are least trained with ALS?

[Trvlr]

You misunderstood my question. Many ALS systems operates with 1 EMT and 1 paramedic on the truck. If the patient requires no ALS interventions, the paramedic drives, and the EMT is in the back with the patient. If they require ALS, the EMT drives. if it's borderline, usually the EMT drives and the paramedic does the stare of life.

Fire/EMS here, that's how we do it in our system. However our department is pushing to get a lot of the EMT-B's to AEMT for the reasons mentioned above about assisting in ALS procedures, drugs, etcs.

I'd also say a majority of the calls that end up "ALS" are more so for pain management and comfort measures that aren't necessary to save life or limb.

 

[DragonClaw]

You misunderstood my question. Many ALS systems operates with 1 EMT and 1 paramedic on the truck. If the patient requires no ALS interventions, the paramedic drives, and the EMT is in the back with the patient. If they require ALS, the EMT drives. if it's borderline, usually the EMT drives and the paramedic does the stare of life.

So in your ride alongs, with minimal interventions performed, do you think having a paramedic there helped the patient? or could the patient have been treated appropriately with just an EMT crew?

I see your point. It's a good one.

Where's a shirt, I need to eat it.

What's the "Stare of life" because most states I know are Death Stares.

 

[DrParasite]

What's the "Stare of life" because most states I know are Death Stares.

The stare of life wasn't covered in your EMT class? epic fail......

the stare of life is simply monitoring your patient. You can also have the IV lock of life, where all a paramedic does is set up an IV lock in the patient's arm, and then monitor the patient on the way to the hospital. The sarcasm involved questions how much does simply having that IV access affect the patient's condition?

Basically, when you aren't doing any interventions for a patient (no meds, no breathing treatment, no electricity, no chest decompression, no intubation, you get the idea), but transporting them to the hospital for definitive care by an MD.

 

[DesertMedic66]

You misunderstood my question. Many ALS systems operates with 1 EMT and 1 paramedic on the truck. If the patient requires no ALS interventions, the paramedic drives, and the EMT is in the back with the patient. If they require ALS, the EMT drives. if it's borderline, usually the EMT drives and the paramedic does the stare of life.

So in your ride alongs, with minimal interventions performed, do you think having a paramedic there helped the patient? or could the patient have been treated appropriately with just an EMT crew?

The stare of life. I’m gonna have to use that one.

 

[rescue1]

Since I finally get to look at this stuff from the other side in the ED, I can share some of my experiences. I remember how stressed people (myself included) would get over whether or not certain patients were ALS or BLS patients. Was their pressure too high for an EMT to ride it in? This patient is concerning for a cervical fracture--is that ALS? People would get in trouble for 'inappropriately' BLSing syncope. People would wait on scene with stroke patients so ALS could ride it in.

Rest easy, because 90% (or more, probably) of the time it makes absolutely no difference. Hypertension? Doesn't matter. Stroke, assuming no airway compromise? ALS saves nurses the 30 seconds it takes to put in a line. I remember medics rushing in a patient who they described as a "really interesting case" who was discharged two hours later. Meanwhile, private BLS units who may or may not have actually taken vitals would drop off floridly septic geriatrics from the nursing homes who would end up in the ICU.

There are certainly patients that benefit from ALS--certain respiratory emergencies, early recognition of STEMI, status epilepticus, hypoglycemia--but there are a large majority of patients who aren't going to need or benefit from ALS procedures. There's also a lot of controversy on whether certain procedures are beneficial in the long run (prehospital intubation has been the big one for the last decade or more, ALS trauma care is another).

All of that being said, the most important thing a paramedic brings to the table vs an EMT is education, understanding of pathophysiology, and experience, so I strongly disagree with the idea that we should lower EMS education any more than it already is.

 

[wtferick]

Since I finally get to look at this stuff from the other side in the ED, I can share some of my experiences. I remember how stressed people (myself included) would get over whether or not certain patients were ALS or BLS patients. Was their pressure too high for an EMT to ride it in? This patient is concerning for a cervical fracture--is that ALS? People would get in trouble for 'inappropriately' BLSing syncope. People would wait on scene with stroke patients so ALS could ride it in.

Rest easy, because 90% (or more, probably) of the time it makes absolutely no difference. Hypertension? Doesn't matter. Stroke, assuming no airway compromise? ALS saves nurses the 30 seconds it takes to put in a line. I remember medics rushing in a patient who they described as a "really interesting case" who was discharged two hours later. Meanwhile, private BLS units who may or may not have actually taken vitals would drop off floridly septic geriatrics from the nursing homes who would end up in the ICU.

There are certainly patients that benefit from ALS--certain respiratory emergencies, early recognition of STEMI, status epilepticus, hypoglycemia--but there are a large majority of patients who aren't going to need or benefit from ALS procedures. There's also a lot of controversy on whether certain procedures are beneficial in the long run (prehospital intubation has been the big one for the last decade or more, ALS trauma care is another).

All of that being said, the most important thing a paramedic brings to the table vs an EMT is education, understanding of pathophysiology, and experience, so I strongly disagree with the idea that we should lower EMS education any more than it already is.

Tell me about it lol
Our directors are having meetings with EMS. Tired of getting all these stroke patients sent BLS to us. With the EMTs telling us "language barrier."

 

[johnrsemt]

What can a medic do for a stroke patient that a basic can't do?
Put them on a monitor and do a 12 lead: won't make much difference: I have seen stroke patients sent to CT before that was done.
IV: saves the ED a couple of minutes.
When I was a basic and on a BLS truck we would transport emergent to the closest appropriate hospitals and not wait on scene for the medics. 9/10 times the medics would be disregarded cause they wouldn't be able to catch us: CVA's, Possible MI's, Resp Distress and Failure, Severe allergic reactions. Load and go.

 

[DesertMedic66]

What can a medic do for a stroke patient that a basic can't do?
Put them on a monitor and do a 12 lead: won't make much difference: I have seen stroke patients sent to CT before that was done.
IV: saves the ED a couple of minutes.
When I was a basic and on a BLS truck we would transport emergent to the closest appropriate hospitals and not wait on scene for the medics. 9/10 times the medics would be disregarded cause they wouldn't be able to catch us: CVA's, Possible MI's, Resp Distress and Failure, Severe allergic reactions. Load and go.

Depending on your area: Assess the patients BGL to make sure it’s not just a glucose issue and advanced airway management should the patients condition deteriorate.

 

[wtferick]

What can a medic do for a stroke patient that a basic can't do?
Put them on a monitor and do a 12 lead: won't make much difference: I have seen stroke patients sent to CT before that was done.
IV: saves the ED a couple of minutes.
When I was a basic and on a BLS truck we would transport emergent to the closest appropriate hospitals and not wait on scene for the medics. 9/10 times the medics would be disregarded cause they wouldn't be able to catch us: CVA's, Possible MI's, Resp Distress and Failure, Severe allergic reactions. Load and go.

Most stroke related patients require at least 2 I.Vs in case they are administered TPA. The medic best have started at least one solid line...

 

[DrParasite]

Depending on your area: Assess the patients BGL to make sure it’s not just a glucose issue

in many places, checking a BGL is an EMT skill.... and a really easy one too..... I really wish more states allowed EMTs to do it....

and advanced airway management should the patients condition deteriorate.

Sure.... but how often does that really happen? I will agree that an advanced airway is needed if the patient's condition does deteriorate. could that be managed as effectively by an OPA and BVM if ALS was not on scene?

Most stroke related patients require at least 2 I.Vs in case they are administered TPA. The medic best have started at least one solid line...

Why? can't the ER start a line or two? does the delay in transport benefit the patient? And are those stroke patient's getting tPA, or is an interventional neurologist going to pull the clot out once the CT shows where it is? or is the patient going to the neuro ICU if they are beyond the window?

 

[wtferick]

in many places, checking a BGL is an EMT skill.... and a really easy one too..... I really wish more states allowed EMTs to do it.... Sure.... but how often does that really happen? I will agree that an advanced airway is needed if the patient's condition does deteriorate. could that be managed as effectively by an OPA and BVM if ALS was not on scene?
Why? can't the ER start a line or two? does the delay in transport benefit the patient? And are those stroke patient's getting tPA, or is an interventional neurologist going to pull the clot out once the CT shows where it is? or is the patient going to the neuro ICU if they are beyond the window?

How would a delay in transportation occur? If the Medic could not establish a line, this patient practically arived BLS.

 

[DesertMedic66]

in many places, checking a BGL is an EMT skill.... and a really easy one too..... I really wish more states allowed EMTs to do it.... Sure.... but how often does that really happen? I will agree that an advanced airway is needed if the patient's condition does deteriorate. could that be managed as effectively by an OPA and BVM if ALS was not on scene?

That’s why I said “depending on your area”. If the patient is also not able to swallow and/or maintain their airway that EMT has no way of correcting the BGL since oral glucose is contraindicated.

My base had a scene call for a stroke patient a couple of days ago. During the 50 minute flight to the closest stroke center the patient ended up becoming unresponsive with multiple episodes of vomiting. A BVM + OPA isn’t going to protect this patients airway mixed with the fact that EMTs are not able to deep suction (in my area). That would have resulted in a dead patient very quickly and very easily.

 

[Tigger]

That’s why I said “depending on your area”. If the patient is also not able to swallow and/or maintain their airway that EMT has no way of correcting the BGL since oral glucose is contraindicated.

My base had a scene call for a stroke patient a couple of days ago. During the 50 minute flight to the closest stroke center the patient ended up becoming unresponsive with multiple episodes of vomiting. A BVM + OPA isn’t going to protect this patients airway mixed with the fact that EMTs are not able to deep suction (in my area). That would have resulted in a dead patient very quickly and very easily.

I think we often forget that CVAs are not always just hemiplegic and sometimes it takes more than a quick ride in to properly manage these patients. We will also bring CVAs to our local primary stroke center, get a CT, assist the facility with starting tPA if appropriate, and then monitor the infusion while starting (if needed) antihypertensives enroute to the comprehensive center. We are not CCT, but we do educate our people extensively to provide this service. I do not think such an integrated system would be possible with just BLS ambulances, and there certainly aren't enough nurses to assist in this in the area.

I spent some time in New Zealand and was quite envious of their EMS system. Paramedics have 3 year bachelor degrees and have ~70% of the US scope to include "essential ACLS drugs," cardioversion, pacing, symptom management meds, 12-lead EKG, and the other litany. No intubation, pressors, or blockers but they could call for an intensive care paramedic for that plus RSI and the other cool stuff. NZ Paramedics can handle 90% of their patients without assistance and have the education to so. They take many of the high risk/low frequency meds and procedures and give that to an elite group. This is the kind of tiered system I long for.

Yes, in many cases all paramedics are doing is making people feel better. Even pretty sick people could probably survive a taxi ride with some vitals and oxygen, but maybe we could do better than that?

 

[rescue1]

I think we often forget that CVAs are not always just hemiplegic and sometimes it takes more than a quick ride in to properly manage these patients. We will also bring CVAs to our local primary stroke center, get a CT, assist the facility with starting tPA if appropriate, and then monitor the infusion while starting (if needed) antihypertensives enroute to the comprehensive center. We are not CCT, but we do educate our people extensively to provide this service. I do not think such an integrated system would be possible with just BLS ambulances, and there certainly aren't enough nurses to assist in this in the area.

I think you're speaking to a very rural coverage area, which has a very different need in regards to ALS--especially when many of your patients are going to be transferred to larger regional care centers by you, or may have 30-60 minute initial transport times.

If you have a ten minute transport and the patient is not in respiratory compromise, the ability to start an IV and get a twelve lead are not going to impact patient outcomes, since these are simple procedures that may even be repeated anyway in the ED. While stroke patients may have a deterioration of their airway, a BLS provider should be able to manage an airway with suction/BVM for 5-10 minutes, and many ALS services may not have RSI capabilities anyway (and prehospital RSI itself can be hotly debated). Also, the vast majority of stroke patients will not deteriorate that significantly in a ten minute transport.

BGL should 100% be a BLS skill, but in areas where it is not it's probably the best indication for ALS in an area with relatively quick transport times. Yes, the hospital is going to recheck it anyway, but hypoglycemia that can be treated on scene can save the system (and patient) a lot of time and money.

Now, all of this being said, I'm not advocating for a mass purging of paramedics in favor of a bunch of undertrained EMT-Bs in every large city, but I am saying that sometimes we take the ALS/BLS split a bit too seriously when for the vast majority of patients it likely does not impact their clinical outcome.

 

[SentinelGary]

For the mention of rural services with extended travel times...

I for one can say that although many services (especially urban and suburban areas) may not necessarily need ALS, it is a crucial part of rural services. Like many in Kansas, our county spans wide enough where there are times it can take upwards of 45 minutes to get on scene. Without ALS intervention, there are several calls that I have been on that would have undoubtedly went sideways. Pnuemo’s than need intubation cannot wait 45 minutes for intervention, MI’s that are refractory need epi/ami, violent patients need benzo. There is such an extreme need for ALS in rural areas, but many boards don’t recognize this because most of their members are from urban areas. Without these ALS providers, our save count would surely plummet in rural services.

My director preaches on this to our A’s all the time. He is the only rural member of our board, and the one of the only reasons we still have the benefit of having A’s in Kansas. You can argue the need for ALS all day, but in the end, services like mine still require all aspects of ALS to give the care our patients deserve.

 

[DrParasite]

Pnuemo’s than need intubation cannot wait 45 minutes for intervention, MI’s that are refractory need epi/ami, violent patients need benzo. There is such an extreme need for ALS in rural areas, but many boards don’t recognize this because most of their members are from urban areas. Without these ALS providers, our save count would surely plummet in rural services.

Don't Pnumos need a chest tube? maybe a needle decompression to start, but their end goal is a chest tube right? I don't think intubation would be my first go to intervention.... or even in the top 3.... how many pnuemos have you see that got tubed?

Don't most MIs need a cath lab? maybe if they code they get epi, but the current studies show that survival rates are increased though early CPR/compressions and defib, not epi... although ami is def indicated if they are in a bad rhythm, to stabilize them until you get to the cath lab.

While benzos are great for violent patients, what was done before? you restrain the patient (or even better, let LEO restrain them), and restrain them to the cot, and take them in kicking and screaming. Been there, done that. Yeah, chemical restraints are generally better than physical ones, but both do work.

Please don't misunderstand, paramedics are great for a small subset of patient's (think bad asthmatics, CHFs, chest pain in identifying a STEMI and activating the CATH lab), they can initiate many life saving interventions (needle decompression, intubate airway burns, RSI if you need it), and they can give meds to make a patient more comfortable (zofran, pain meds, etc), and I am not advocating for getting rid of them, esp in the rural areas, but statistically, how much impact do the have on the mortality of the all the patients seen by rural EMS?

 

[SentinelGary]

For lack of statistics off the top of my head, I am just making an educated guess. All I’m saying is that we have extensive use of ALS in areas like mine where all we have is sub-par level V’s in the area. I don’t know all that much about interventions, but I know there have been patients where our BLS crew had no idea what to do, and when ALS was called they were able to intervene. One example is the use of D50, I suppose. The real difference is education.

My viewpoint is against being just the wee-woo wagon. We have our equipment and staff, but when it boils down to it, we don’t have a hospital on wheels. Many of the skills that patients need, including just a higher knowledge of pathophysiology, we can’t give to BLS crews. Services out here are lucky as it is to have more than 20 EMT’s, much less an A or medic. Most if not all EMT’S are trained at a local service with an Ed program, and they don’t have time for advanced A&P education. They get basics, and maybe a little ways further.

 

[Tigger]

Please don't misunderstand, paramedics are great for a small subset of patient's (think bad asthmatics, CHFs, chest pain in identifying a STEMI and activating the CATH lab), they can initiate many life saving interventions (needle decompression, intubate airway burns, RSI if you need it), and they can give meds to make a patient more comfortable (zofran, pain meds, etc), and I am not advocating for getting rid of them, esp in the rural areas, but statistically, how much impact do the have on the mortality of the all the patients seen by rural EMS?

Measuring outcomes only off mortality benefits has and will always do EMS a huge disservice. There is more to healthcare than life, death, and "save counts."

 

[DragonClaw]

Measuring outcomes only off mortality benefits has and will always do EMS a huge disservice. There is more to healthcare than life, death, and "save counts."

But if he dies, like really dies, you can't measure any of the others. I don't know how many people would be affected by having any EMT B knowing ALS, but it would be interesting to get large sample data to analyze

 

[johnrsemt]

I like the idea of rural areas with 45 minute response time: ours is 45 minutes to get a helicopter to us. We have up to 2 hours response time, then 2 hours back to the base area, then 90 minutes to 2 hours to hospital by ground if we are lucky (a couple of weeks ago from base area it took 4.5 hours due to heavy snow).
I had to ground transport an Acute MI Friday due to not being able to get a helicopter in the air due to bad winds at all of their bases. Then the ED doctor argued with us about it being a true MI (over the phone and in person) but when the cardiologist saw the 12 leads, the patient went straight to the cath lab. ED doc didn't show the cardiologist the 12 leads until we arrived.