Jobs not "trusting" emt-b?

Tigger · Jul 28, 2015

Many of the positive outcomes EMS seeks are not easily quantifiable either. Symptom relief is something that EMTs struggle with, but also does not really show up in morbidity and mortality numbers. Yet much of EMS has deemed it important, and I agree with that. Perhaps maybe we need to start objectively looking at other ways paramedics improve outcomes aside from life and death emergencies?

Uclabruin103 · Jul 28, 2015

Worked for a company that started always dispatching ALS crews to everything. Why? ALS assessment fees. $$$$$ the only thing this world cares about.

And as for what paramedics do on BLS calls. I think of it this way. If I have something in my box that'll make their stay in the ER shorter like starting a bolus, or getting pain Meds rolling when I really could have shipped it, I'll do it. Let's get the ball rolling before having to be seen by the doc.

NomadicMedic · Jul 28, 2015

Tigger said:
Many of the positive outcomes EMS seeks are not easily quantifiable either. Symptom relief is something that EMTs struggle with, but also does not really show up in morbidity and mortality numbers. Yet much of EMS has deemed it important, and I agree with that. Perhaps maybe we need to start objectively looking at other ways paramedics improve outcomes aside from life and death emergencies?

Agreed. Maybe paramedic efficacy can be quantified by customer satisfaction.

Press Ganey might have a new revenue stream.

Carlos Danger · Jul 28, 2015

Tigger said:
Many of the positive outcomes EMS seeks are not easily quantifiable either. Symptom relief is something that EMTs struggle with, but also does not really show up in morbidity and mortality numbers. Yet much of EMS has deemed it important, and I agree with that. Perhaps maybe we need to start objectively looking at other ways paramedics improve outcomes aside from life and death emergencies?

It is true that not all outcomes are easily quantified. Fortunately, the real important ones - morbidity and mortality - are.

When I say that paramedic-level skills are necessary on very few transports, I'm lumping analgesia for severe pain in with status asthmatics and seizures.

Tigger · Jul 28, 2015

Remi said:
It is true that not all outcomes are easily quantified. Fortunately, the real important ones - morbidity and mortality - are.

When I say that paramedic-level skills are necessary on very few transports, I'm lumping analgesia for severe pain in with status asthmatics and seizures.

About 20% of our transported patients received some form of analgesics last year. I'd hardly say that qualifies as very few.

Carlos Danger · Jul 28, 2015

Tigger said:
About 20% of our transported patients received some form of analgesics last year. I'd hardly say that qualifies as very few.

And I would bet the demographics and acuity of the patients you transport are fairly atypical, as well.

Plus, just because an analgesic is given doesn't mean that that the patient wouldn't have done just fine with other measures.

46Young · Jul 28, 2015

I think that the best system would be the dual medic fly car with a BLS fleet. The medics would only need to txp real ALS patients, which is very refreshing when the typical street medic runs tons of BLS. In lieu of that type of system, in an urban or populous suburban area, there's no reason why a tiered system with lots of BLS and a handful of ALS won't work (see KCM1). The way I see it, if the caller doesn't give a good enough story to get an appropriate response (BLS vs ALS), the onus is on them, not dispatch. BLS can be trained to recognize early when ALS should be called. The BLS can have a full set of vitals, record Hx/demographics, and package while ALS is enroute. Overall, the time from dispatch to arrival at the ED shouldn't be much different than if the ALS were there first. If ALS was there first, a crew of two, they would be getting vitals and gathering a Hx, much like the BLS are doing if they get there first. It's not that big of a deal to send BLS first on calls that are not reported by the caller to be ALS worthy.

nick Joseph · Jul 28, 2015

I think it's a little ridiculous to send medics on every single call, and make it seem like all EMT's are incompetent. while I agree you cannot know if it's als or bls in most cases, I do not see how sending a medic to " injuries from a fall " (in my dispatch they tell you if it was high or low) on a 60 year old pt is warranted, especially if you've been to the persons house on multiple calls before and they're a regular.

medichopeful · Jul 29, 2015

nick Joseph said:
I think it's a little ridiculous to send medics on every single call, and make it seem like all EMT's are incompetent. while I agree you cannot know if it's als or bls in most cases, I do not see how sending a medic to " injuries from a fall " (in my dispatch they tell you if it was high or low) on a 60 year old pt is warranted, especially if you've been to the persons house on multiple calls before and they're a regular.

Falls in the older population can have the potential to be very, very serious. Deadly, in fact. Although some might argue that 60 isn't too old, it would e pretty easy to argue that this patient has the potential to be ALS level

Tigger · Jul 29, 2015

Remi said:
And I would bet the demographics and acuity of the patients you transport are fairly atypical, as well.

Plus, just because an analgesic is given doesn't mean that that the patient wouldn't have done just fine with other measures.

We are your typical semi-suburban/rural community. On average I'd say our patients are higher acuity than urban areas (though I cannot prove that) just based on the sort of hardy person that lives up here. They don't call until they need it (on average).

We would not be providing analgesics if other measures were effective, that's the whole point.

EMS needs to move away from basing its effectiveness purely on morbidity and mortality. It is the most important measure, but it is not the only measure. We provide healthcare in a different setting than most, but that does not excuse us from being held to the greater industry standard. Whether I agree with it or not, patient satisfaction is in fact important, and symptom control and relief plays a big role in that. Maybe it's not making a huge difference in the health status of our patients, but if we want even a tiny seat at the industry table, we're going to have to play by their rules.

I should add that there is no reason why this can only be done by a paramedic. It is not unreasonable to think that a marginally better educated Advanced EMT could provide many of these treatments. But we aren't there yet, so paramedics it will be.

Carlos Danger · Jul 29, 2015

The OP asked a reasonable question: Why aren't EMT's more widely utilized? (paraphrased)

The real answer - and I don't think anyone has mentioned this yet - is billing.

An EMS agency can charge much more for an ALS transport than it can for a BLS transport. Take a patient with belly pain 10 minutes from the hospital who could easily be transported BLS, and put him in an ALS ambulance. The paramedic will put the patient on the monitor or pop in an IV because the ED nurses have come to expect it, and there you go.....the extra money you make in that one transport by billing ALS vs. BLS is likely more than enough to cover the extra $60 or $80 that it costs you to have a paramedic on that ambulance for the shift instead of a second EMT. The actual difference in reimbursement depends on which payor is being billed, of course, and if the payor agrees that ALS was medically necessary. But on average, over a handful of transports, the ALS unit will make more money than a BLS one, even transporting the same exact patients, and no matter how unhelpful the ALS care was.

Everything else - improved assessment skills, improved ability to recognize "sick" vs. "not sick", ability to give drugs, yada yada.....it just doesn't matter in most cases. It seems like it should - I agree - but the research is pretty consistent on this. If you are having a refractory asthma attack or a prolonged seizure, then being treated and transported by a paramedic vs. an EMT might improve your chances of a positive outcome. But that's about it. If you have long transport times, then the advantages of a paramedic are probably magnified. But for most busy systems, it's a small percentage of transports where paramedics help. In most systems, all you need is decent triage and a couple ALS units to cover those few calls where ALS really matters, and system-wide, your patients will do just as well as if every ambulance had a paramedic on it.

Perhaps they'd actually do better with fewer paramedics. There's not much research on this that I know of, but I strongly suspect that skills dilution in systems where there are lots of paramedics is a bigger problem than we realize. It's shown to be true among physicians. Being really good at managing a crashing patient takes experience and practice. And there are only so many crashing patients to go around in the field.

The analgesia thing is a little tricky. But in all honesty, I think the pendulum has swung a little too far here. I think we make a bigger deal about it than it really is. We've gone from when I was a young paramedic, in most systems someone had to be screaming bloody murder in the background before OLMC would give you orders for 2mg of morphine, to these days where paramedics compete with each other over who can give the most fentanyl in a shift. People who are really hurting deserve our best efforts at making them comfortable, of course. But I don't think that means everybody who is in any amount of pain has a right to opioids, which is how many seem to interpret the recent emphasis on patient comfort.

Measurable metrics are what we are stuck with. Most of the non-measurable ones have nothing to do with ALS vs. BLS anyway, they have to do with professionalism and common sense.

triemal04 · Jul 29, 2015

It's interesting to read some of the replies when this topic invariably comes up. More so now with the advent of community paramedicine/healthcare. It does bring a couple things to mind.

Many of the people who get "symptom relief" or have something done "to make their stay in the ER shorter" are exactly the people who don't need an ER in the first place; the ones who would be better suited by going to an Urgent Care, their PCP, or even staying at home after consulting with someone with a decent amount of medical knowledge. As the medical community changes, and the expectations for what will happen in/out of a hospital changes, why would EMS want to go in the opposite direction? Is this just another sign that EMS is, as a whole, generally 5-10 years behind the rest of the medical community?

The other thing that comes up (and was recently brought up elsewhere) is that there is a bit of hypocrisy involved in this. Paramedics advocate for seeing all patients and treating each and every single thing possible, even if it really doesn't matter, didn't need to be done, and in fact is an innapropriate use of a hospitals time (since that's where those patients will end up). Of course, this means that there will need to be a vast amount of paramedics to cover the "demand" and perceived "need." Just like those dirty fire departments keep their hands in EMS so that there is a "demand" and perceived "need" for them to keep their numbers up. Slightly hypocritical, but that's just my opinion.

joshrunkle35 · Jul 29, 2015

Let's not forget that paramedics can still do BLS. It's not ALS vs BLS. It's BLS vs BLS/ALS.

TransportJockey · Jul 29, 2015

**** that als vs bls ********. Its first aid vs medicine. I'm so sick of basics who feel threatened by medics or are afraid pf going and getting more education that just spout idiotic sayings that are so old and tired I wanna scream
Ok. I feel better now lol

46Young · Jul 30, 2015

Mid-level practitioners (NP, PA) are well equipped to handle the vast majority of urgent care and ED patients. EMT-B's are equipped to handle the vast majority of patients that request 911. The two situations are really not all that different. Just like I'm burnt from running mostly non-acute, stable 911 patients in my all-ALS deployment system, I'm sure that an ED Doc can burn out from having to work with the same stable people that turn up in the ED every day, who use the ED as their PCP.

RocketMedic · Jul 31, 2015

I think a huge part of the answer is that the education of an EMT-B is so woefully inadequate that many common chronic complaints and mimics are falsely interpreted as acute, time-sensitive situations and are treated and received as such. Paramedics are not immune, but it is not as frequent.

evantheEMT · Oct 25, 2015

Wow, I'm glad I work where I work as bls we go to all kinds of emergency calls.

evantheEMT · Oct 25, 2015

joshrunkle35 said:
And yet, on those very few times that the difference in assessment skills are needed, BLS would not know what they don't know and would have no clue that they might be missing something that may require intervention.

Why don't we have bus drivers or lifeguards transport people? Because intervention while enroute may be necessary. How would someone know when it is necessary? Through assessment training. If we could have doctors do the job, that would be ideal, however, it is unrealistic in nearly all systems. It is realistic in many systems to have some form of paramedic available, and their assessment skills should be utilized as often as possible and as often as affordable for the system.

Why are you grouping all emts together? That's insane just like grouping all medics in the same group saying they're all amazing.

evantheEMT · Oct 25, 2015

Remi said:
The OP asked a reasonable question: Why aren't EMT's more widely utilized? (paraphrased)

The real answer - and I don't think anyone has mentioned this yet - is billing.

An EMS agency can charge much more for an ALS transport than it can for a BLS transport. Take a patient with belly pain 10 minutes from the hospital who could easily be transported BLS, and put him in an ALS ambulance. The paramedic will put the patient on the monitor or pop in an IV because the ED nurses have come to expect it, and there you go.....the extra money you make in that one transport by billing ALS vs. BLS is likely more than enough to cover the extra $60 or $80 that it costs you to have a paramedic on that ambulance for the shift instead of a second EMT. The actual difference in reimbursement depends on which payor is being billed, of course, and if the payor agrees that ALS was medically necessary. But on average, over a handful of transports, the ALS unit will make more money than a BLS one, even transporting the same exact patients, and no matter how unhelpful the ALS care was.

Everything else - improved assessment skills, improved ability to recognize "sick" vs. "not sick", ability to give drugs, yada yada.....it just doesn't matter in most cases. It seems like it should - I agree - but the research is pretty consistent on this. If you are having a refractory asthma attack or a prolonged seizure, then being treated and transported by a paramedic vs. an EMT might improve your chances of a positive outcome. But that's about it. If you have long transport times, then the advantages of a paramedic are probably magnified. But for most busy systems, it's a small percentage of transports where paramedics help. In most systems, all you need is decent triage and a couple ALS units to cover those few calls where ALS really matters, and system-wide, your patients will do just as well as if every ambulance had a paramedic on it.

Perhaps they'd actually do better with fewer paramedics. There's not much research on this that I know of, but I strongly suspect that skills dilution in systems where there are lots of paramedics is a bigger problem than we realize. It's shown to be true among physicians. Being really good at managing a crashing patient takes experience and practice. And there are only so many crashing patients to go around in the field.

The analgesia thing is a little tricky. But in all honesty, I think the pendulum has swung a little too far here. I think we make a bigger deal about it than it really is. We've gone from when I was a young paramedic, in most systems someone had to be screaming bloody murder in the background before OLMC would give you orders for 2mg of morphine, to these days where paramedics compete with each other over who can give the most fentanyl in a shift. People who are really hurting deserve our best efforts at making them comfortable, of course. But I don't think that means everybody who is in any amount of pain has a right to opioids, which is how many seem to interpret the recent emphasis on patient comfort.

Measurable metrics are what we are stuck with. Most of the non-measurable ones have nothing to do with ALS vs. BLS anyway, they have to do with professionalism and common sense.

Youre exactly right, als because the pt needs a "pulse ox". Ok, so let's bill thousands of dollars to look at numbers.

evantheEMT · Oct 25, 2015

TransportJockey said:
**** that als vs bls ********. Its first aid vs medicine. I'm so sick of basics who feel threatened by medics or are afraid pf going and getting more education that just spout idiotic sayings that are so old and tired I wanna scream
Ok. I feel better now lol

OR medics that are threatened by bls care doing more.

Jobs not "trusting" emt-b?

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