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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A good teacher and mentor once told me"there is no ALS without good BLS".

Doug



Doug Harwood said:

A good teacher and mentor once told me"there is no ALS without good BLS".

Doug

 

What is BLS

What is ALS

I see patients.

I see individuals.

I see diseases.

My patients do not care what BLS is.

My patients do not care what ALS is.

My patients care that I have the necessary ability to implement appropriate interventions.

Exactly why I get frustrated with the "too many paramedics" debate. In my opinion, the more education and training the better! Now I know some of you are going to say, "But what about skill dilution?" to which I echo the comments of others who have said, "Is it skill dilution or 'never had the skill in the first place'"? If the latter, then let's not pretend like we're going to solve the problem by sending even less trained emergency professionals out on the street to save our loved ones' lives. At any rate, I agree! Who cares if it's "BLS" or "ALS"? What matters is that it's indicated, performed expertly, and provides a benefit to the patient.

Tom


Joe Paczkowski said:



Doug Harwood said:

A good teacher and mentor once told me"there is no ALS without good BLS".

Doug

 

What is BLS

What is ALS

I see patients.

I see individuals.

I see diseases.

My patients do not care what BLS is.

My patients do not care what ALS is.

My patients care that I have the necessary ability to implement appropriate interventions.

I do think skill dilution is an issue with too many paramedics. I think the bigger problem, though, is [pulls on nomex suit] that the current option is either everything (paramedics) or nothing (EMTs) in terms of depth of education and scope of practice. Yes, a large amount of patients could find their way to the hospital via taxi without any additional harm. Yes, a minority of patients are critical and need intubation and other low use, high risk interventions.

What about the middle? Do we really need a paramedic to treat hypoglycemia? Do we really need a paramedic to provide pharmaceutical pain management? No, but we need someone with more than 110 or 150 hours of training.

However I think the biggest issue in terms of dilution isn't tiered vs all paramedic ambulance deployment schemes, but the systems that puts a paramedic on every vehicle with red lights and sirens. It's strange that those systems don't do that with the other specialty positions (i.e. haz-mat, swift water rescue, high angle rescue, etc).

Do we really need an ED physician to treat hypoglycemia? We could train anyone to start an IV and push D50 but that's not the point. I believe that every EMS patient deserves to be evaluated by someone with the education, training and experience to perform an adequate patient interview and physical exam and understand enough about medicine to triage, risk stratify, or form a differential diagnosis as needed. Not to mention determining who is safe to leave at home. We're both agreed that it takes more than 110 or 150 hours of training to get there. Where we disagree (apparently) is whether or not the current paramedic curriculum is adequate, let alone EMT-basic. Who do you want responding to one of your parents? I'll take the competent, experienced professional, regardless of what the emergency might be. It's not at all clear to me that it can't be done. As is frequently pointed out on this forum, the other first world countries seem to manage.

Tom

Well how do we feel about making the EMT scope more broad for things like glucometry and basic ekg reading and starting lines with fluid bags? I personally feel annoyed when I have an unconscious patient with a history of diabetes and can't find a blood sugar because it is out of my scope. Correct me if I'm wrong but basic things like that EMT's learn the concept of through out their career it will make calls easier and not tie up paramedics with calls that can be easily managed by EMT's.

No... and how many systems allow treat and release of hypoglycemia? So no all patients seeking help through the EMS system (inclusive of prehospital and ED care) are being seen by an emergency physician. Additionally, it ignores the economy of scale present in the ED where the physicians are seeing many patient (often more than the nurses are seeing).

I agree that every patient should get someone competent, professional, etc. However, since you brought up international counterparts, let's look at Canada. For the provinces that use the primary care paramedic/advanced care paramedic system, my understanding is that the primary care paramedics have about the length of education as our paramedics, but a scope of practice somewhere between an I/85 and I/99. Their emergency medical responder level is basically analogous to our EMTs in the sense of scope of training, except they aren't considered as a primary responder (i.e. can't transport themselves). The advanced care paramedic is about a year more education and has a scope similar to the more liberal EMS systems in the United States.

As such, the level that is most analogous to our paramedics is not what a lot of patients are getting, but the lowest level is far beyond our EMTs. Of course this illustrates an important difference regarding education. In the US, our education is downward pointing triangle. We give EMTs just enough information to do without thinking, and then provide all of the foundational information (anatomy, physiology, etc), along with attempting to change the attitude from technician to professional, in paramedic programs. In Canada, it's a upward pointing triangle. The vast majority of foundational information is taught to the PCPs with only the more specialty information required to go from PCP to ACP.

It's also my understanding that the non-emergent IFT system is completely separate from the 911 system. Practically speaking, we don't need an ambulance and a paramedic or EMT for your standard discharge or dialysis transport. However the legal and financial situation in most areas requires it, which means the private IFT companies have a financial reason to fight increased training in areas that aren't pertinent to the medical taxi business.

The problem with "making the EMT scope more broad" is today, and has been for 30 years, the resistance of those EMTs to the education necessary to support the expanded scope.  While some states are beyond reason (my 11 year old can take a blood sugar, but there are places where an EMT can't), there is an institutional ignorance about the implications of performing treatments and administering drugs without having the knowledge of anatomy, physiology, pathophysiology, and pharmacology of those skills, procedures, drugs, etc.  No patient should be subject to treatment by an ignorant, uneducated provider!

So, the EMT takes the blood sugar.  What does he or she do with that information?  Does he or she have the education to realize what might be causing the hypo- or hyper-glycemia?  So now, we let the EMT wake the patient up with some glucose.  Now the patient doesn't want to go to the hospital.  What does the EMT do?  Is the hypo- due to too much insulin, not enough food, or are oral hypoglycemics involved.  HINT - the answer is not the same for each scenario.  What does our EMT do now?  Some of the choices, which will be selected at random, because the EMT doesn't understand the kinetics of glucophage, can result in the patient going hypo- after the EMTs let him sign the refusal.  Oops!  Dead!  I guess some EMS systems would tolerate that sort of outcome, but mine will not.

Robert Valdora said:

Well how do we feel about making the EMT scope more broad for things like glucometry and basic ekg reading and starting lines with fluid bags? I personally feel annoyed when I have an unconscious patient with a history of diabetes and can't find a blood sugar because it is out of my scope. Correct me if I'm wrong but basic things like that EMT's learn the concept of through out their career it will make calls easier and not tie up paramedics with calls that can be easily managed by EMT's.

That's it, Scott.

The issue with USA EMT-B today, and approaching it from a scope of practice perspective, is that it is all "do" and very little "know."  "Do" without "know" is simply dangerous.  "Do" without "know" is looking at EMS from the perspective of the medic - and to do it right, we have to look at it strictly from the perspective of the patient!

Scott and Skip the new EMT curriculum just recently expanded to twice the class length and four times the hospital observation. But there are ALS procedures that can be done by an EMT no problem. Hypothetically speaking say I'm dispatched to the south side of my jurisdiction for a chest pain. If my scope and education taught ECG interpretation and allowed my crew to hook up a 4-lead and see if it's a cardiac problem or not then I wouldn't hold up the medic crew sent out to me if they're needed on the north side for a MCI or cardiac arrest.



Robert Valdora said:

Scott and Skip the new EMT curriculum just recently expanded to twice the class length and four times the hospital observation. But there are ALS procedures that can be done by an EMT no problem. Hypothetically speaking say I'm dispatched to the south side of my jurisdiction for a chest pain. If my scope and education taught ECG interpretation and allowed my crew to hook up a 4-lead and see if it's a cardiac problem or not then I wouldn't hold up the medic crew sent out to me if they're needed on the north side for a MCI or cardiac arrest.

Hypothetically, you would know that the filter is different on a 4 lead continuous cardiac monitor vs a 12 lead EKG, and thus wouldn't use a 4 lead cardiac monitor to look for a STEMI. This is, of course, assuming that the patient isn't having an NSTEMI or another problem. Otherwise you can be like the DC crew that because a case study on stupidity for dismissing a pulmonary embolism as GERD.

"....allowed my crew to hook up a 4-lead and see if it's a cardiac problem or not...."


That's the problem - not knowing what you don't know, over-simplification of complex matters, etc..  You can't "hook up a 4 lead" and determine whether a complaint is a cardiac problem or not! You can have many cardiac problems, including a full-blown STEMI, that shows little besides normal sinus rhythm on a 3 or 4 lead ECG.  And now, this patient who needs a 12-lead ECG, pain control, and perhaps other things has to wait an additional 10 minutes while you call for and get, or meet, the proper EMS resource!  Who are we helping here?

You can teach anybody to DO a variety of ALS procedures.  What you can't do, in a limited number of hours (and now that the EMT curriculum is 140 or so hours, it's STILL way to short) is teach the person to know WHEN those procedures should be done, WHAT might go wrong, and what the ramifications of doing that procedure might be.

I don't know why this is so hard to understand - it's NOT ABOUT PROCEDURES!!!  It's about assessment, diagnosis, and developing a complete and correct plan of care.  The standard of care in the US is that if the dispatch information indicates chest pain, a paramedic unit gets sent.  If the south side of your jurisdiction deserves any less, I don't understand why.

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