Okay so in my town my buddy and I always question if a cardiac arrest is necessarily a need for ALS or if more BLS hands on is what it will take to make resuscitation more likely. For those who are curious we live in NJ in case someone was curious as to what scope of practice we have.

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Neil, make no mistake, we're budget-oriented and target-oriented as well as patient-oreinted.  However, we design our targets (standard of cover) to be patient-oriented, and we design our budget to support the standard of cover.

Neil White said:

and there's the UK lucky just to get a single crew there on time.....would love to work in a system that was patient orientated rather than budget and target orientated. 

Give us a few years, we'll catch up!

I cannot believe that you compared ALS to GPS!! You wonder why there is tension between you (the BLS/ volunteers) and us (the MICU). BLS in the state of NJ is not up to standards compared to other states, which you can thank the FAC for. BLS does not get enough exposure to critical patients by only "riding" once a week in a town that is 5 - 6 sq miles. Apparently you do not understand what ALS is and what the current trends are in EMS. Besides peds or extreme circumstances codes are worked where they are (home, nursing homes). We do not transport codes unless ROSC is achieved (again unless in certain circumstances) . The reason is we are not going to risk anyone getting hurt or killed from accidents rushing dead bodies to the ER. ALS has all the tools the ER does in terms of running a code. Also just because you have a few  nursing courses under your belt does not make you a paramedic or superior to a paramedic. Again we get that from a lot of nursing students/emts in the area. Nursing is different from paramedicine. We (at least in Nj) spend as much time if not more time in school than nurses do. IE prerequisites for medic school (college Math, English and sciences), medic school (2 - 2 1/2 years ) plus many also get their RN/BSN after medic school.  I am sorry if I am being harsh, but until BLS get over their egos and entitlement mentality, ALS will always have problems w the "squads". With that being said, I want to let you know that Most of us are very approachable and are more than happy to help if you have a question. 

Josh perhaps your point would have been better if you talked across to someone and not down at them?

BLS does not get enough exposure to critical patients by only "riding" once a week in a town that is 5 - 6 sq miles

I wonder if those staffing the helmand province would agree with this??

Nursing is very different to EMS education, EMS needs to know the science behind what they do, so they know that when protocol A tells them to stick a F*** off cannula anywhere near places you'd not normally put one, the medic has selected protocol A for the right reasons. Nursing focusses on a much more holistic approach to patient care, exploring all nature of needs from chronic illness through to social care. This is where EMS needs to be and from the many many conversations we have on the subject no one is really sure how to get there. 

One thing that really does get my back up is this BLS/ALS divide, we all wear the same uniform and all poo sitting down so treating a patient not as a patient but rather as a shopping list of interventions that I can do that you can't really helps no-one. 

I'm all for non transport of arrests, we need to move away from false hope resus, where we literally flog a dead horse (or person) for no reason as to massage our own egos, if CPR doesn't start the moment the person hits the ground and a defib isn't followed up <3 minutes later there's no point even discussing intubation.

These full codes we see where a relative has been doing lack lustre CPR for the last 15 minutes prior to a crew arriving and we follow up with a half arsed covering protocol need to stop. Let a person die with some dignity. 

Okay, as a nursing student who is aspiring to become and MICN I will say this; nursing preps you for in facility situations where it is a lot more stable and you have other nurses and higher medical authorities available if need be. I ride 2 volunteer squads and it gives me a wide variety of job experience due to the area difference and demographics and blah blah blah. Paramedic school preps you for being out on the streets and performing ALS which is not as easy. I will agree with Neil that this ALS/BLS divide needs to go; however, it is not always present. Whenever I get a job with 1 particular medic we stick to patient care but also discuss the possible causes to the illness or why she starts an 1000 bag wide open or just anything that she can teach me and that i can comeback and say "Hey, why does one have a fruity breath odor during a diabetic emergency?", and on other occasions I'll see a different medic and they just have this demeanor that their time is being wasted which now puts my crew in a tough spot. But back to the original topic at hand. Whether you are a medic or a nurse or an EMT, you can still work with and learn from each other. Animosity between healthcare providers will do nothing but inhibit patient care.

Josh, you're way out of line.  The "ALS/BLS divide" is a creation of the wierd EMS system in NJ, and is not a factor anywhere else.  The people you are talking to are professional EMS officers in large, first class EMS systems from across the world.

There are plenty of "BLS" services around that run thousands of calls per year with very professional, very well qualified personnel who do a great job.  The problems that you're speaking of have to do with very small, all volunteer agencies, not a BLS/ALS separation.  You only get to that discussion when you're arguing about the organization rather than the welfare of the patients.

Not so sure the ALS / BLS divide thing isn't going on in Pennsylvania as well...paid and volunteer included.  But I agree with Skip, if we put the patient first, that all goes out the window and we are all on the same team, working together to meet the patient's needs.


You're right, Paula - it goes on in other places where different levels of service are sometimes provided by different agencies.  The division is not necessarily BLS/ALS, but poor inter-agency coordination, with the patient as the beneficiary.

What is different is that NJ has, since the beginning of time, institutionalized that split by the state statute that says that "ALS" is provided only by hospitals.  The split is further magnified there because much of the state is served by volunteer local BLS, while all the paramedics are pretty much career personnel.

Skip and Paula I agree with you. What I would like to see is a system with one paramedic/MICN and one EMT on a truck. ALS jobs the medic/MICN take patient care while the BLS jobs the EMT take care of this way there is more of an appreciation going on. And Skip, after I started to become a paid EMT I realized that there is a different standard to care then volunteers. I still volunteer and I love helping my community but on my volunteer duty night myself and my partner approach every job as if we were on our paid division because we feel many volunteers do not treat EMS how it should be. We feel that yes it is a volunteer organization but the only way we can improve ourselves and ultimately give the patient there best care is to keep in mind, "This is someone's life. This is my job to help them." and not the "oh well I'm a volunteer. no big deal" attitude. I also feel that in EMT school they should focus more on maintaining a professional attitude and attire. I see too many EMT's wearing jeans and a shirt that says EMT or just plain clothes with a squad jacket on.

That is a different design - it may work well or it may not, depending on the place.  If you go to "all ALS units" you may wind up with so many paramedics that each one does few ALS skills, thereby loosing proficiency.  There is some data that suggest that "too many paramedics" results in worse patient outcomes.

Two-tiered systems seem to generate good outcomes in relatively compact geographic areas (like Seattle and Boston).  They are often too expensive to operate in less densely populated areas, because you need more of both to cover the geography, but the call demand isn't there.

As long the patient is the consideration, and the decisions are made based on what is best for the patients (and not the medics or the organization or the system), we will be at least heading in the right direction.

Patient care is always first and foremost after the safety of myself, my crew, and my additional resources. It can be difficult for us while dealing with family and bystanders. I was on a job a few weeks ago that came in as an unconscious. Upon arriving the patient was showing stroke symptoms with a CVA within the last year. While we were 2 minutes out from a stroke center the daughter in law insisted we went to a facility 30 min away because it was more convenient for the family. At this point the medics wanted us to comply while myself and my partner felt that at least getting the patient to the stroke center and having them stabilized first was more important. What in your opinion is the best way to go about this? I don't want to force hospitals onto anyone unless it is an absolute necessity (i.e. trauma or burn center or busy shift with the need for a quick turn around)

PATIENTS always have the right to make stupid or wrong decisions, provided that they maintain decision-making capacity.  DAUGHTERS-IN-LAW do not.  Your duty in that situation is to do what is right for the patient, which means getting him to the proper hospital (I hope that your protocols spell out acute stroke criteria and prescribe destinations).  This is a time dependent thing, so after you've safely delivered him, then you explain to the distant family why this was the right thing to do.  If family convenience is important, the patient can be transferred AFTER he has had his 'lytics or percutaneous intervention (whatever the stroke center has to offer).

If you're the BLS guy and the ALS guys are there and caring for the patient, the best you can do is explain to them what you recommend and why.  Hopefully they too will come to the same conclusion (if your protocols and theirs are in harmony and make sense).  This multi-agency thing has so much potential for harmful error, I'm surprised that communities aren't trying to do something to make it go away.

It can all work - then those pesky human beings become involved, and it all gets complex.

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