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Cardiac Arrest. BLS or ALS job?
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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Replies to This Discussion
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Permalink Reply by Duncan Hitchcock on -
Ignorance is a treatable condition. Education is the key.
Several of the "arguments" presented thus far sound like the whine I've heard all too often from both EMT and Paramedic students, and, EMTs and Paramedics working in the field...."Why do I need to know that?" (A whine I heard only once during nursing school by a classmate that shortly thereafter left the program.)
If you want to be a First Aider...close your mind and be statisfied with doing things. If you want to be an EMT or Paramedic, be prepared to constantly expand your knowledge and, hopefully, your understanding of the what the patient is experiencing, why and thereby make an intelligent decision as to how to treat them.
Knowing how is only part of patient care. We must why and when to do the right thing.
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Permalink Reply by Neil White on -
Taking it from our side of the pond and this is more prevalent at the moment, but our agencies are run by non clinical managers people for whom business takes precedence over patient.
So if we we're to take the chest pain patient for example, we can all agree the key steps;
(1) Some form of assessment
(2) Oxygen
(3) Pain Relief
(4) ECG
(5) Transport to ER or PPCI
If we then look at evidence collated that the majority of patients presenting to an ED by ambulance with chest pain are discharged post Troponin as non cardiac. We start to paint a picture that in fact for the chest pain, EMS' bread and butter call a paramedic level clinician is not really required at any part of the patient journey.
An EMT crew could perform a SAMPLE history, could undertake a 12 lead and using LifePak or the others transmit technology send it for interpretation. There is much support for moving to non IV analgesics, Oramorph and the like....Aspirin and GTN are both at EMT proficiency in the UK. Driving the Patient to an ER or PPCI requires somebody trained to drive. If the patient should arrest, AED is available, Oral Airways and the various drugs are gradually becoming obsolete.
SO from a financial point of view a £250,000 vehicle staffed with 2 £8 - £10 per hour EMT's are perhaps as capable of dealing with a call that their £17 - £20 per hour paramedic counterparts.
This is why the UK model is shifting to 1 paramedic on a response car to every 6 Double EMT vehicles. We're (as in the royal we're) are still confident that a paramedic will be sent to every patient that needs one, and the efforts to reach an accurate telephone assessment continue.
Whether that's the right course of action or not is difficult to tell because the majority of the UK paramedic's time is spent dealing with urgent care problems because of a poor out of hours primary care system and a social decline in the ability to care for one's self even with the slight of sniffle.
I think its less about education standards and more about whats financially viable with every government budget being slashed around us.
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Permalink Reply by Joe Paczkowski on -
Oxygen is only indicated in a hypoxic patient. Hypoxia and ischemia are cousins, but not the same. [insert reperfusion injury and free radical comment here]
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Permalink Reply by Skip Kirkwood on -
So how's that working out for clinical outcomes, and for patient satisfaction?
Neil White said:Taking it from our side of the pond and this is more prevalent at the moment, but our agencies are run by non clinical managers people for whom business takes precedence over patient.
So if we we're to take the chest pain patient for example, we can all agree the key steps;
(1) Some form of assessment
(2) Oxygen
(3) Pain Relief
(4) ECG
(5) Transport to ER or PPCI
If we then look at evidence collated that the majority of patients presenting to an ED by ambulance with chest pain are discharged post Troponin as non cardiac. We start to paint a picture that in fact for the chest pain, EMS' bread and butter call a paramedic level clinician is not really required at any part of the patient journey.
An EMT crew could perform a SAMPLE history, could undertake a 12 lead and using LifePak or the others transmit technology send it for interpretation. There is much support for moving to non IV analgesics, Oramorph and the like....Aspirin and GTN are both at EMT proficiency in the UK. Driving the Patient to an ER or PPCI requires somebody trained to drive. If the patient should arrest, AED is available, Oral Airways and the various drugs are gradually becoming obsolete.
SO from a financial point of view a £250,000 vehicle staffed with 2 £8 - £10 per hour EMT's are perhaps as capable of dealing with a call that their £17 - £20 per hour paramedic counterparts.
This is why the UK model is shifting to 1 paramedic on a response car to every 6 Double EMT vehicles. We're (as in the royal we're) are still confident that a paramedic will be sent to every patient that needs one, and the efforts to reach an accurate telephone assessment continue.
Whether that's the right course of action or not is difficult to tell because the majority of the UK paramedic's time is spent dealing with urgent care problems because of a poor out of hours primary care system and a social decline in the ability to care for one's self even with the slight of sniffle.
I think its less about education standards and more about whats financially viable with every government budget being slashed around us.
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Permalink Reply by Nathan Stanaway on -
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.
The reason its so hard to understand is because the education level is sooooo low. Its that simple. Ignorance is bliss, unless your the patient!
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Permalink Reply by Rogue Medic on -
EMTs (and many Medics) Just don't know what they don't know.
Amen.
As long as we are more interested in putting more medics on more trucks, that will only get worse, unless we aggressively do something to counteract this skill dilution.
Why not make every doctor a trauma surgeon, so that wherever we go, there's a trauma center?
Won't the community be thrilled to have trauma surgeons everywhere?
We know that skill dilution is a myth.
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Permalink Reply by Robert Valdora on -
Well Skip I wasn't aware of the problem with using 4-leads compared to 12-leads. Trust me I'm all about learning as much as I possibly can about EMS. So what would you like to see in the scope of an EMT?(with of course the proper education to follow)
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Permalink Reply by Skip Kirkwood on
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I don't approach life in terms of scope of practice, so here's what I think the ROLE of an EMT-B (I'd sure prefer if we called them primary care paramedics, like they do in Canada) should be:
Basic Life Support initial response, with AED, CPR, ASA, oral glucose, epi auto-injector. Primary assessment, bandaging and splinting. Patient movement, packaging, ambulance driving. Far more in the way of geriatrics, indigent care, drug abuse and additionology. Perhaps some other language capability. Writing!
We would invert the educational pyramid (like all the other health professions in the US, and including EMS overseas), where all the A&P for the whole pyramid would be learned up front, along with English and the other basic science courses. So the entry level program would be 12-18 months of full-time school (associate degree). Paramedic (advanced care) would be another 2 years. Specialty care (flight, critical care, community) would be another year and would award a Master's degree.
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Permalink Reply by Skip Kirkwood on
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I agree with most of your premise, but how do we know that skill dilution is a myth? I know that my psychomotor skills, whether EMS or other (I used to shoot competitive pistol) decay without practice. Got some data that says otherwise?
Rogue Medic said:EMTs (and many Medics) Just don't know what they don't know.
Amen.
As long as we are more interested in putting more medics on more trucks, that will only get worse, unless we aggressively do something to counteract this skill dilution.
Why not make every doctor a trauma surgeon, so that wherever we go, there's a trauma center?
Won't the community be thrilled to have trauma surgeons everywhere?
We know that skill dilution is a myth.
.
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Permalink Reply by Tom Bouthillet on -
I think we first need to demonstrate that our paramedics have the skills in the first place before we speculate about skill dilution.
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Permalink Reply by dr-exmedic on -
Skip Kirkwood said:
I agree with most of your premise, but how do we know that skill dilution is a myth? I know that my psychomotor skills, whether EMS or other (I used to shoot competitive pistol) decay without practice. Got some data that says otherwise?
Skip, time for you to get more sleep! It's Rogue, he was being sarcastic. ;)
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Permalink Reply by Rogue Medic on
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Here are some studies addressing the problems with experience dilution -
The association between emergency medical services staffing pattern...
Eschmann NM, Pirrallo RG, Aufderheide TP, Lerner EB.
Prehosp Emerg Care. 2010 Jan-Mar;14(1):71-7.
PMID:19947870 [PubMed - indexed for MEDLINE]-
Out-of-hospital endotracheal intubation experience and patient outc...
Wang HE, Balasubramani GK, Cook LJ, Lave JR, Yealy DM.
Ann Emerg Med. 2010 Jun;55(6):527-537.e6. Epub 2010 Apr 14.
PMID: 20138400 [PubMed - indexed for MEDLINE]-
How would minimum experience standards affect the distribution of o...
Wang HE, Abo BN, Lave JR, Yealy DM.
Ann Emerg Med. 2007 Sep;50(3):246-52. Epub 2007 Jun 27.
PMID: 17597255 [PubMed - indexed for MEDLINE]-
Expertise in prehospital endotracheal intubation by emergency medicine physicians-Comparing...
Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Arntz HR, Mochmann HC.
Resuscitation. 2012 Apr;83(4):434-9. Epub 2011 Oct 29.
PMID: 22040777 [PubMed - in process]-
Performance and skill retention of intubation by paramedics using s...
Ruetzler K, Roessler B, Potura L, Priemayr A, Robak O, Schuster E, Frass M.
Resuscitation. 2011 May;82(5):593-7. Epub 2011 Feb 24.
PMID: 21353364 [PubMed - indexed for MEDLINE]-
EMS-physicians’ self reported airway management training and expert...
Rognås LK, Hansen TM.
Scand J Trauma Resusc Emerg Med. 2011 Feb 8;19:10.
PMID: 21303510 [PubMed - indexed for MEDLINE]-
Ability of First-Year Paramedic Students to Identify ST-Segment Ele...
Levis JT, Koskovich M.
Prehosp Disaster Med. 2010 Nov-Dec;25(6):527-32.
PMID: 21181687 [PubMed - indexed for MEDLINE]-
Ambulance personnel perceptions of near misses and adverse events i...
Cushman JT, Fairbanks RJ, O’Gara KG, Crittenden CN, Pennington EC, Wilson MA, Chin NP, Shah MN.
Prehosp Emerg Care. 2010 Oct-Dec;14(4):477-84.
PMID: 20662679 [PubMed - indexed for MEDLINE]-
Pre-burn center management of the burned airway: do we know enough?
Eastman AL, Arnoldo BA, Hunt JL, Purdue GF.
J Burn Care Res. 2010 Sep-Oct;31(5):701-5.
PMID: 20634705 [PubMed - indexed for MEDLINE]-
Simulation-based mock codes significantly correlate with improved p...
Andreatta P, Saxton E, Thompson M, Annich G.
Pediatr Crit Care Med. 2011 Jan;12(1):33-8.
PMID: 20581734 [PubMed - indexed for MEDLINE]-
Lack of association between prehospital response times and patient outcomes.
Blackwell TH, Kline JA, Willis JJ, Hicks GM.
Prehosp Emerg Care. 2009 Oct-Dec;13(4):444-50.
PMID: 19731155 [PubMed - indexed for MEDLINE]-
Factors influencing decision making among ambulance nurses in emerg...
Gunnarsson BM, Warrén Stomberg M.
Int Emerg Nurs. 2009 Apr;17(2):83-9. Epub 2009 Jan 4.
PMID: 19341993 [PubMed - indexed for MEDLINE]-
Retention, learning by doing, and performance in emergency medical ...
David G, Brachet T.
Health Serv Res. 2009 Jun;44(3):902-25. Epub 2009 Mar 5.
PMID: 19292773 [PubMed - indexed for MEDLINE]-
Cardiac Arrest Survival Rates Depend on Paramedic Experience
Michael R Sayre, Al Hallstrom, Thomas D Rea, Lois Van Ottingham, Lynn J White, James Christenson, Vince N Mosesso, Andy R Anton, Michele Olsufka, Sarah Pennington, Stephen Yahn, James Husar, Leonard A Cobb.
Academic Emergency Medicine; Volume 13 Issue s5; May 2006; pages S55 – S56; abstract number 121http://roguemedic.com/2009/09/too-many-medics-comment-from-anonymous/
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I eagerly await your research demonstrating that experience doesn’t matter.
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