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

DragonClaw

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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.
Is that some sort of malpractice if he was harmed by the delay?
 

Tigger

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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
Indeed this research has been done at times. However the general end goal is show mortality benefit, of which for many patients who receive paramedic care there is none. If this is the only reason to have paramedics (mortality rates decrease), then it is not worth having paramedics in many cases. Many of us however believe that there is more to this job than just "life saving" however the additional benefits that paramedics provide are not well researched. Things like pain control and symptom relief do not save lives. Yet according to the rest of healthcare, they matter and I tend to agree. We just don't seem to care.

Also an "EMT knowing ALS" would be considered an Intermediate or Paramedic (maybe an Advanced if you really stretch the definition). If an EMT wants to be trained in ALS, they can go to school for that...
 

DragonClaw

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Indeed this research has been done at times. However the general end goal is show mortality benefit, of which for many patients who receive paramedic care there is none. If this is the only reason to have paramedics (mortality rates decrease), then it is not worth having paramedics in many cases. Many of us however believe that there is more to this job than just "life saving" however the additional benefits that paramedics provide are not well researched. Things like pain control and symptom relief do not save lives. Yet according to the rest of healthcare, they matter and I tend to agree. We just don't seem to care.

Also an "EMT knowing ALS" would be considered an Intermediate or Paramedic (maybe an Advanced if you really stretch the definition). If an EMT wants to be trained in ALS, they can go to school for that...
I agree there's more to life saving, but compared to pain control, it's not as big a priority in that moment. I mean, a bruise due to a fall, vs the guy with sucking chest wound because he got shot. Of course, the frequency of occurrences are probaby not even in the same category, so maybe I'm talking myself into a corner.

And regarding that, I almost mentioned the same thing, with the exception of maybe a little more training for BLS. I mean, from what I understand things like BGL and Epi are pretty easy, so why not make sure that's standard for BLS? From reading, (not on experience, correct me if I'm wrong), even a needle decompression or a placing 12-lead shouldn't be / that/ hard.
 

mgr22

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And regarding that, I almost mentioned the same thing, with the exception of maybe a little more training for BLS. I mean, from what I understand things like BGL and Epi are pretty easy, so why not make sure that's standard for BLS? From reading, (not on experience, correct me if I'm wrong), even a needle decompression or a placing 12-lead shouldn't be / that/ hard.
A misconception about paramedics among some EMTs is that meds and procedures are the most significant differences between those two levels. That's not true. The main differences are what paramedics are expected to know and how they're supposed to apply that knowledge. To stick with one of your examples, giving epi is easy, but knowing the subtleties involving risks, benefits, and options is much more challenging.
 

rescue1

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Indeed this research has been done at times. However the general end goal is show mortality benefit, of which for many patients who receive paramedic care there is none. If this is the only reason to have paramedics (mortality rates decrease), then it is not worth having paramedics in many cases. Many of us however believe that there is more to this job than just "life saving" however the additional benefits that paramedics provide are not well researched. Things like pain control and symptom relief do not save lives. Yet according to the rest of healthcare, they matter and I tend to agree. We just don't seem to care.

Also an "EMT knowing ALS" would be considered an Intermediate or Paramedic (maybe an Advanced if you really stretch the definition). If an EMT wants to be trained in ALS, they can go to school for that...
There are studies that show mortality benefit to ALS, mostly chest pain/cardiac patients and respiratory patients.

I agree with you about symptom relief, though I'm of the mind that most of the basic symptom relief meds (ondansetron, diphenhydramine, ketorolac, acetaminophen, etc) should be provided at the BLS level (though not at the current BLS level of education).
 

DragonClaw

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A misconception about paramedics among some EMTs is that meds and procedures are the most significant differences between those two levels. That's not true. The main differences are what paramedics are expected to know and how they're supposed to apply that knowledge. To stick with one of your examples, giving epi is easy, but knowing the subtleties involving risks, benefits, and options is much more challenging.
There are studies that show mortality benefit to ALS, mostly chest pain/cardiac patients and respiratory patients.

I agree with you about symptom relief, though I'm of the mind that most of the basic symptom relief meds (ondansetron, diphenhydramine, ketorolac, acetaminophen, etc) should be provided at the BLS level (though not at the current BLS level of education).
That's what I meant when I said EMT B having ALS skills. More tools, but knowing how and when to use them or not use them is just as important.
 

rescue1

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That's what I meant when I said EMT B having ALS skills. More tools, but knowing how and when to use them or not use them is just as important.

Like @Tigger said earlier, that's the model that most Commonwealth countries use (Canada, UK, Australia, NZ). They have a basic paramedic level which operates on what we'd call AEMT (which is usually a 3 year degree), and then advanced paramedics who do what we'd call ALS.

I'd be all for this system, but so far no one wants to pay for it haha.
 

SentinelGary

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I personally like the idea of BLS trained with some ALS skills, mainly because that’s what my service does. We are spoiled in that Kansas has a pretty wide scope for all levels of prehospital care, and my service allows us the full scope. It works very well here, because as volunteers we don’t always know if we are leaving with BLS or ALS, and like I said before: in a rural service, ALS is crucial.

That’s my two cents anyways.
 

Tigger

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We should not just be giving EMTs more and more "skills" without changing the educational process. Colorado essentially allows EMTs to practice at the AEMT level through waivers and add on classes, for a total of maybe 30 extra hours. The standard for these classes is poorly defined and there are minimal CE requirements for them. To top it off, we don't even know if it there is benefit to a lot of this. Do I think that EMTs placing SGAs is a good thing and helps patients? Yup sure do. How about EMTs starting IVs? Who knows? We never looked. It makes my job easier, but do I want an EMT who runs 30 calls a years to be starting IVs and pushing D50? I'm not sure.

It's not all about skills. Too often EMS adds things because it makes the providers feel good.
 

DrParasite

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I would love for EMTs to be able to do more. Give benedryl, insert a SGA, give albuterol for wheezing, check BGL and SQ epi would be a great start (NJ didn't allow any of that when I was up there). Clear C-spine in the field would be another (rumor has it we can do that in the next 12 months).

I would LOVE to give IM zofran. PO/SL is nice, but IM is even nicer (administration is just like giving Epi), and makes patients feel so much better. Nothing to do with providers feeling good, that would help the patients.

Start IVs? ehhhhh, maybe if they are on an ALS unit and partnered with a paramedic, otherwise, a (relatively) lot of training for low reward. Ditto intubation. Nice to have, but does it really benefit the patient? ehhhh.

But I also agree that the education is lacking.
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.
There is a HUGE difference between having no idea what to do, and knowing what is needed but being unable to provide the intervention. If you have a patient with a BGL of 30, and then have no idea what to do, then their initial EMT training failed them.

However, if they recognize that they identify the issue, recognize they can't fix the issue, and package the patient for transport, so when the ALS unit arrives, all they need to do is administer D50, and then the patient can either be transported or not (depending on local protocols, reason sugar dropped, etc), well, that's a different story.

If you need a medic to hold your hand and tell you what to do, than that's your issue. Not every EMT is like that. In fact, many tiered EMS system have EMTs like that, because you don't have ALS with you on every call, so you are expected to know how to do your job.
 

rescue1

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I think the national standard for AEMT covers about 90% of what people would find useful on the vast majority of EMS runs. I think it's something like: albuterol, epinephrine IM, glucagon/dextrose, naloxone, nitrous oxide, nitro/ASA, plus IV/IO access + fluids, CPAP, and supraglottic airways. The only things I would add would be diphenhydramine and maybe Zofran, like @DrParasite said.
BGL and clearing c-spine should be a given just for being on an ambulance but I know some places are very behind.
I wish the AEMT class was longer than 500 hours but I think it's a whole lot better than EMT-B class.

Things like cardioversion/pacing, ACLS drugs, needle decompression, etc should be reserved for paramedic level training. These are the high acuity patients that benefit from more educated providers. Same goes with intubation--I don't think there is any place for BLS intubation, and you could easily make the argument that there might not be a place for routine prehospital intubation at all.

To disagree with DrParasite though, I don't think that we can say that people's BLS/EMT training failed them when they **** the bed, metaphorically, on calls. I was prepared for absolutely nothing after my EMT class--thanks to having some good partners and being a huge nerd who researched stuff I managed to figure everything out, but the class itself was not a strong foundation. Yes, there are going to be prodigies who take an EMT course and immediately grasp everything, but the vast majority of people are going to need more than the basic class, and many of them will not have exposure to a good FTO system--many will start off at a crappy IFT job, or at a small town volly squad where bad habits have been passed down for generations.
 

johnrsemt

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At an A&R (Audit and Review) our Medical Director did years ago, a few EMT-B's asked why they weren't allowed to do Albuterol (Neb) blood glucose, SL NTG (not patients) and something else.
Medical Director asked them what the BLS Protocol was for Cardiac Chest Pain: it took 4 EMT-B's almost 5 minutes to get the BLS protocol right: 324 mg ASA, chewed; 02 above 95%; help pt with NTG if they have their own and it isn't expired; head for a hospital that has a cath lab and call for a medic but if you can get to the hospital faster than meeting with a medic cancel the medic and just go to the hospital.

Doctor told them that is why he has a problem adding to their protocols
 

DragonClaw

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At an A&R (Audit and Review) our Medical Director did years ago, a few EMT-B's asked why they weren't allowed to do Albuterol (Neb) blood glucose, SL NTG (not patients) and something else.
Medical Director asked them what the BLS Protocol was for Cardiac Chest Pain: it took 4 EMT-B's almost 5 minutes to get the BLS protocol right: 324 mg ASA, chewed; 02 above 95%; help pt with NTG if they have their own and it isn't expired; head for a hospital that has a cath lab and call for a medic but if you can get to the hospital faster than meeting with a medic cancel the medic and just go to the hospital.

Doctor told them that is why he has a problem adding to their protocols
Fair, but, if someone isn't allowed to use a skill, do you expect them to know it? Maybe you do for simple things. So, why not train them properly then ask that question again?
 

mgr22

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Fair, but, if someone isn't allowed to use a skill, do you expect them to know it? Maybe you do for simple things. So, why not train them properly then ask that question again?
I think you misunderstood: They WERE trained to treat chest pain at a BLS level, but didn't know the protocol.
 

DrParasite

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At an A&R (Audit and Review) our Medical Director did years ago, a few EMT-B's asked why they weren't allowed to do Albuterol (Neb) blood glucose, SL NTG (not patients) and something else.
Medical Director asked them what the BLS Protocol was for Cardiac Chest Pain: it took 4 EMT-B's almost 5 minutes to get the BLS protocol right: 324 mg ASA, chewed; 02 above 95%; help pt with NTG if they have their own and it isn't expired; head for a hospital that has a cath lab and call for a medic but if you can get to the hospital faster than meeting with a medic cancel the medic and just go to the hospital.

Doctor told them that is why he has a problem adding to their protocols
What did they not know? I remember in my EMS academy/orientation for my former job, there were written exam questions about whether the proper dose for ASA was 324 or 325..... Also, do you give oxygen if their SPO2 was 94 or below, or below 95.... did they not know the 5 rights?

I'm guessing your agency does annual competencies right? to verify that they know what is expected of them? and con ed to correct any deficiencies? Looks like your agency's training officer/department has a pretty serious failure, if they haven't verified that their personnel know the proper BLS protocols.

I would also hypothesize that if your EMTs are always paired with a medic, and the medic always calls the shots and tells the EMTs what to do, what dosages to give, and when to give it, then your EMTs don't need to know any of that information, because the medic will be telling them (but will agree they should know their protocols). Now if they don't always have a medic, and still don't know, then yes, that's a pretty serious issue, one that should be addressed by your training department.
I think you misunderstood: They WERE trained to treat chest pain at a BLS level, but didn't know the protocol.
Well, I was trained to give activated charcoal.... and apply MAST pants.... haven't had charcoal in almost 10 years.... MAST pants in almost 20.....

But if more than one person doesn't know the protocol, and they are expected to know the protocol, that seems to be more of a system problem, vs an individual competence problem.
 

photog

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Here's how EMS is organized in my country. Typically it consists of five different levels.

1. FIRST RESPONDER (minimum of 32 hours of training)
- Usually voluntary fire departments
- Equipment: AED, oxygen, OPA, SGA (typically iGel), BVM, diagnostic tools (SpO2, BP, b-Gluk, b-Keto, temp, alco etc), normal first aid kits, vacuum splints, rescue tools etc. Some units carry p.o. glucose, EpiPen and CarboMix.
- Usually respond to most urgent calls only.
- Fire truck ("engine") or FD owned SUV / minivan equipped with mentioned equipment

2. BLS (either 2-3 years of second level school (combined "EMT" and "CNA") or professional firefighter school (1,5 years of which 6 months is dedicated to EMS)
- All of the above, plus: monitor-defibrillator (LifePak 15, Zoll X-Series etc), 15-lead ECG, i.v. equipment, CPAP
- Salbutamol, adrenaline, i.n. midazolam, i.n. fentanyl, iv fluids (RAC, G10%)
- Typically operate "normal" ambulances (MB Sprinters and equivalents)

3. ALS (Minimum of a 4-year B.Sc in emergency care -degree (combined RN + "paramedic"), usually also 1-2 years of BLS experience required)
- All of the aboce, plus a rather wide range of i.v. / i.m / s.c / inh. meds (all your typical ALS meds including opiates, ketamine, cardiac drugs, benzos, TXA, narcan, flumazenil, thrombolytics, steroids, drug infusions etc)
- TC pacing, cardioversion, intubation, i.o. drills, cric kits, ped kits etc. LUCAS and NIV (Oxylog / Hamilton) also in some units.
- Typically operate "normal" ambulances. Also one-person fly cars in some areas.

4. FIELD SUPERVISOR (B.Sc in emergency care + typically studies in EMS management or nowadays M.Sc in health sciences or emergency care - a total of 4-6 years)
- All of the above plus some extra meds (second line seizure drugs, more anesthetics, CyanoKit etc)
- Respirator (Oxylog or Hamilton), video laryngoscope, i-stat / Epoc, LUCAS
- Blood products in some units
- Typically respond in fly-cars / SUV

5. EM DOCTOR (typically specialized either in anesthesiology & intesive care or acutology - total of 12 years)
- All of the above plus even more drugs and blood products
- Possibility for clamshell thoracotomy, thoracostomy, emergency c-cection and other surgical emergency procedures
- Typically respond in helicopters or minivans in some areas. Mostly helicopters.


That's it. The backbone of our EMS system are ambulances manned with two persons. One BLS, one ALS. Therefore most of our ambulances operate on ALS level. There are also BLS-only ambulances in larger cities that take care of the low-risk calls and also respond to high-risk calls as first responders.

I know I'm propably not completely objective, but I kind of like our 5-tier system.
 
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OceanBossMan263

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NY has begun to allow EMT to use CPAP, draw up and inject IM epi, and to acquire and transmit (not interpret) 12-lead EKG. The epi was mainly a response to the enormous price of auto-injectors. Each skill requires the agency to gather approval from the region and then ensure training for individual providers.

The AEMT course has come to my region to fill some of the void left by the departure of EMT-Critical Care, but there isn't much of a market for providers at that level and it shows in the attendance. They're taught IVs, ET/combi (though my region doesn't allow the use of ET, feeling that many at that level don't come with a ton of experience), D50, and maybe a select few other drugs. No cardiology.
 

DesertMedic66

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NY has begun to allow EMT to use CPAP, draw up and inject IM epi, and to acquire and transmit (not interpret) 12-lead EKG. The epi was mainly a response to the enormous price of auto-injectors. Each skill requires the agency to gather approval from the region and then ensure training for individual providers.

The AEMT course has come to my region to fill some of the void left by the departure of EMT-Critical Care, but there isn't much of a market for providers at that level and it shows in the attendance. They're taught IVs, ET/combi (though my region doesn't allow the use of ET, feeling that many at that level don't come with a ton of experience), D50, and maybe a select few other drugs. No cardiology.
The national standard for EMTs has incorporated CPAP, Epi IM, Narcan IN/IM. A decent amount of states have already been allowing their EMTs to do the skills with more areas allowing it.
 
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