is "ALS" a lie?

[Veneficus]

I don't think so. Some tout pre-hospital ultrasound as the next big thing. Is it cool to do?... of course. How will it really change the game? Will the patient be treated any differently?

Having a picture of the inside of somebody doesn't help you with your treatment?

I only see it as a triage tool but since we already over triage as a safety net I don't see any real difference between having ultrasound or not having it in the field.?

That over triage costs an insane amount of money and has to stop. Not everyone needs to be transported to a level I trauma, major cardiac/neuro and other specialty center for every complaint. (even though I think they would be better off) Look at the amount of overuse of airmedical as an example of that. Those are very large bills.

I know EMS providers, and even admit I used to think this way, feel that the cost doesn't matter and it can be worried about later.

That is simply not true.

While I still agree that the cost of treatment should not be a concern, the cost of diagnosis certainly needs to be. Outstanding medical expenses as I understand are the number 1 cause of bankruptcy in the US. Financial troubles the number 4 cause of divorce.

How are EMS providers serving their patients by bankrupting them and breaking up families because they need to so grossly overtriage? (apparently have no idea what they are doing. Or no more idea if a patient needs a hospital or what type than the average person anyway.)

Medicine is not some part of life removed from the rest of it. The purpose of any healthcare provider is to help people. Not to destroy patients lives to give the provider some mental comfort over their personal shortcomings.

If an EMS provider not only doesn't help, but causes harm, why would anyone ever pay for them or even want to call them?

There is already the argument that ALS care delays definitive care and is worse for some patients. Adding to the scene time and trying to do 100 things in 15mins instead of 10 isn't registering with me yet. Like I said previously, when do we reach the threshold of what we should be doing pre-hospital?

I think where prehospital has room to improve is not in doing treatments. It is in figuring out the best entry into the healthcare system for people.

I know that is not the original design, and I know most US providers lack the mental ability to do that for a variety of reasons, but that doesn't mean it shouldn't change.

Why do people call 911?

Becuae they need help.

Do they need medical help? Law enforcement help? Fire help? Rescue? Social?

It is all of these and more. Now I know some "first responders" like to think they are just for emergencies as defined by themselves, but let me point this out in the form of questions.

If you went to a doctor with the same concern would she refuse to make any effort to help you?

When a person asks a police officer for help with something like directions or keys locked in a car or because they thought they saw something suspicious does LE tell them to call back when they recognize a serious crime is being commited?

Does the fire department tell you to call back when you see fire when you tell them you smell smoke?

Do they not show up for all manner of emergency and see if they are able to help?

Calling the fire department and telling them that you smell smoke doesn't result in a box alarm and engine companies tossing 10,000s of gallons of water on your house "just in case."

These two agencies have developed the skills and techniques to respond appropriately to community needs.

EMS wants pay parody, ok, but how about value parody first?

There must be an answer other than an emergecy ride to the ED with IVs and oxygen.

There will always be overtriage, but it cannot continue to be massive. EMS will have to develop the skills and techniques to respond appropriately to what they are called for. They don't need to add another gizmo or procedure that "saves lives in real emergencies" which are only very small fraction of calls. (less than 1 in 10)

We read all the time here about agencies wanting RSI, and all kinds of other procedures and treatments. Why do we not see threads about "What practicle steps can EMS take to address the needs of the callers not needing life saving interventions?"

It seems that EMS providers are more concerned with their own wants than the needs of the patients.

I guess ALS really is a lie. I feel as if I have done a great disservice to a great many people reflecting on what my EMS career entailed.

 

[18G]

Having a picture of the inside of somebody doesn't help you with your treatment?

How does it? In the field were not gonna be operating. I will agree that perhaps the prehospital ultrasound may pick up something early when the patient has yet to display physically. It's kinda like an EMT with a glucometer... what does it really change treatment wise in the field. My views are always open for change but right now I just don't see it changing field care dramatically.

And I do agree with the majority of what your saying. I don't necessarily agree with the over triage to the degree that it is implemented and hate the rash decision that providers make to call for air medical. Providers don't realize (or care) about not only the cost but the risk vs benefit to not only the patient but also to the HEMS crew. Especially given the number of HEMS crashes lately. It's not a decision to make lightly I agree.

I been doing EMS for almost 20 years and have a pretty open mind and view about the EMS system. Is the system really that broken like some portray? I agree that things can be done better and the time is here for a restructuring of the EMS system and a new expanded purpose. This is a HUGE task that I feel will take a few decades to accomplish. So, where is the starting point and how do you suggest we make the wheels turn faster?

 

[Veneficus]

This is a HUGE task that I feel will take a few decades to accomplish. So, where is the starting point and how do you suggest we make the wheels turn faster?

Culling the herd.

 

[firetender]

Time to Chime In!

I'm not sure what's going on here. You're talking like you're trained in medicine. You're not. You're trained to DELIVER medicine. There's a HUGE difference.

You are NOT the experimenter. Remember when the paramedic was the "eyes and hands" of the doctor? Who calls the shots? Well, hopefully, someone who's a bit better trained than YOU!

That's where Standing Orders came from. A group of doctors agreed that certain things could be administered under certain specific circumstances in a specific order without calling in for permission. The parameters had limitations according to the signs and symptoms leading to therapies that had been determined, through clinical study, to be the most consistent agent of the desired changes.

You don't have 1/1000th of the information necessary to call shots in the field that might be experimental. The ER Docs have that choice, but you know what? Even they only have 1/100th of the info THEY need. To a large extent they are largely delivery systems for interventions and therapies that have been proven elsewhere as well. They, however, unlike you, DO have license to experiment.

In the field, at today's level of training, if you're going to be effective, I think it would behoove you to be the best delivery system you can be. There's practicality to that, because the way medicine is set up today, there's more failure in trials than success. Why expose yourself to the liability of answering questions you're simply not trained to answer?

There is ACLS, but it's not determined by you. You can influence HOW you deliver it, but it's really not your job to determine WHAT you deliver and WHEN.

Not until you get way better edumacated. Is that what you want? Is that what you're willing to sacrifice for as Vene, the OP is doing today?

 

[18G]

Is that a general "you" or specific "you" directed at someone specific?

 

[DrParasite]

I'm not sure what's going on here. You're talking like you're trained in medicine. You're not. You're trained to DELIVER medicine. There's a HUGE difference.

You are NOT the experimenter. Remember when the paramedic was the "eyes and hands" of the doctor? Who calls the shots? Well, hopefully, someone who's a bit better trained than YOU!

That's where Standing Orders came from. A group of doctors agreed that certain things could be administered under certain specific circumstances in a specific order without calling in for permission. The parameters had limitations according to the signs and symptoms leading to therapies that had been determined, through clinical study, to be the most consistent agent of the desired changes.

You don't have 1/1000th of the information necessary to call shots in the field that might be experimental. The ER Docs have that choice, but you know what? Even they only have 1/100th of the info THEY need. To a large extent they are largely delivery systems for interventions and therapies that have been proven elsewhere as well. They, however, unlike you, DO have license to experiment.

In the field, at today's level of training, if you're going to be effective, I think it would behoove you to be the best delivery system you can be. There's practicality to that, because the way medicine is set up today, there's more failure in trials than success. Why expose yourself to the liability of answering questions you're simply not trained to answer?

There is ACLS, but it's not determined by you. You can influence HOW you deliver it, but it's really not your job to determine WHAT you deliver and WHEN.

Not until you get way better edumacated. Is that what you want? Is that what you're willing to sacrifice for as Vene, the OP is doing today?

Bingo!!!! Someone else who gets it.

If you want to play doctor (push whatever drugs you think are the best, operate with no safety net, and and not have to deal with protocols), then go to medical school. 4 years for a bachelors, 3-5 for medical school, and throw in a residency for good measure. Then you can have the freedom and expanded scope like some are asking for.

But a paramedics is AN EXTENSION of the ER, and you are operating under your medical director's license. That means he or she who is more knowledgeable and experienced than you tells you what to do (whether it be online or offline medical control), and you do it.

I keep wondering why some people have trouble with this concept

 

[MrBrown]

I keep wondering why some people have trouble with this concept

Because in most other Western nations Paramedics have advanced far beyond being the medical directors' bumboy.

To say they are still an "extention" of a doctor precipitates us to the age old, long outdated notion that Doctor is king and that every patient must be transported to the Doctor.

We leave people at home without asking the doctor, have unlimited drug dosages in line with good clinical praxis and prudent professional judgement without asking the doctor, have no "medical contro" so therefore do not have to ask the doctor for anything and are not bound to follow a "protocol" which blindly seperates patients into standardised treatment pathways thus removing nearly all critical thinking and professional judgement.

It seems that the US will always be comfortable with the "Paratechnician" modality of operating thus limiting the need for critical thinking and sadly also limiting the opportunity for professional advancement.

 

[JPINFV]

...because you can't be a professional while acting like a technician. So pick one. Either be a technician with technician level respect, pay, education, responsibility, and freedom, or be a professional. What can't and won't happen is professional level pay and respect, with some sort of inbetween mush of clinical freedom (the "we don't want to call for everything, unless we can blame it on the physician" BS) and a technician level of responsibility and education. Pick one. I don't care which one, but you can't have it both ways.

 

[clibb]

Veneficus,

I totally agree on some of your opinions.
I think that a lot of ALS agencies are held back. I've read that AMR won't even let their IV CERTIFIED EMT- Basics start IVs. I mean, why not? If you've been trained correctly at it, why not let the person do it.
I'm fortunate enough to ride with a lot of smart people. A lot of these people are Paramedics, that is due to that they wanted to "advance" in EMS and that they have the experience.
But some EMTs that have a ton of years under the belt could without no doubt run an ALS right as a Paramedic without the certificate. They know all the medications, interventions, and how to run calls correctly as a Medic. The only thing the medic does is sit there and actually do the interventions and the medications, since they are cleared to do so. If there is anything the medic doesn't agree on, he/she will do differently. But, great minds think alike, as you pretty much stated.
I think it has a lot to do with the Medical Director, though. If the doc has more trust in his EMS staff, he will let them practice more and better. We are lucky enough to have such a doctor.

That is actually why I wanted to start in EMS to begin with. To get the experience and to see how the streets are run. Then as an MD I will have more confidence in the staff on the streets and trust them with their decisions.

Personally, I think of us in EMS as preventer's, not curers. We prevent until we get to the hospital where the staff there will cure.

 

[MrBrown]

experience and education are not the same thing just because you can administer a medication or intervention does nor make you any more of a clinician and less of a technician

 

[AnthonyM83]

To say they are still an "extention" of a doctor precipitates us to the age old, long outdated notion that Doctor is king and that every patient must be transported to the Doctor.

We leave people at home without asking the doctor, have unlimited drug dosages in line with good clinical praxis and prudent professional judgement without asking the doctor

You can do those things and still be an extension of the doctor. That idea is used to explain the idea that we work within a limited framework of rules (which is absolutely required if we're working under a limited framework of education). Increase the education, THEN we can increase the framework.

 

[Veneficus]

To say they are still an "extention" of a doctor precipitates us to the age old, long outdated notion that Doctor is king and that every patient must be transported to the Doctor.

But I want to be king! h34r:

Clibb,

It is very important that you do not see the skills a paramedic does and think that a basic can do just as good.

While I would agree that you can teach anyone to run a code or follow a protocol even with no medical training, you cannot see the thought process that goes into the decsion making.

That process whether coming from a medic or a doctor is the understahd of "why are we doing this, towards what aim."

As rid pointed out, so few prehospital patients actually need an IV, that the idea of even bothering to train basics to do it is a waste of time and money in all but the most remote of environments, where the options were that or nothing.

I think it is a bit of being new and not knowing what is not known. The higher you advance in medicine, the more tenuous what the providers in the field are doing looks.

(1st world nations with more advanced EMS programs excepted)

 

[18G]

"Education is the discovery of ones own ignorance" - one of my favorite quotes.

 

[firetender]

Is that a general "you" or specific "you" directed at someone specific?

y'all. kinda general trend of the thread sorta thing.

 

[firetender]

Look at our exposure; look at what we do

I'm thinking Mr. Brown here.

The role of a paramedic is short-term intervention in an illness or injury adequate to help the patient attain stability enough to get to a higher level of care.

Am I wrong?

Let's start there.

 

[JPINFV]

I'm thinking Mr. Brown here.

The role of a paramedic is short-term intervention in an illness or injury adequate to help the patient attain stability enough to get to a higher level of care.

Am I wrong?

Let's start there.

Are a lot of the interventions really "short term?"

Isn't an AED really a long term intervention?

What about hanging a bag of dopamine for someone who is hypotensive?

What about CPAP? If you can give an intervention that drastically affects the rest of the patients treatment for the current disease, is it really short term?

Are paramedics who give thiamine for ALOC/drunk patients really treating short term illnesses with it?

 

[firetender]

Are a lot of the interventions really "short term?"

Isn't an AED really a long term intervention?

What about hanging a bag of dopamine for someone who is hypotensive?

What about CPAP? If you can give an intervention that drastically affects the rest of the patients treatment for the current disease, is it really short term?

Are paramedics who give thiamine for ALOC/drunk patients really treating short term illnesses with it?

All of these interventions are short-term with the potential to be utilized long-term. Most are interventions that are begun in the field and very likely to be changed based upon further findings and/or testing. In some cases, they become just the first volley in a juggling act that may or may not help the patient; that's just the way it is.

The goal is to get the patient to a higher level of care, expeditiously, alive and without further harm. Anything else is a bonus.

Does that seem like a reasonable statement of priorities?

 

[DrParasite]

Are a lot of the interventions really "short term?"

yes

Isn't an AED really a long term intervention?

no. it's a short term intervention. it fixes the problem (vfib/vtach), hopefully enough to put the person back in a normal rhythm to stabilize the patient to get to the ER so the doctors can find out why he or she went into cardiac arrest. once they determine the underlying cause, that becomes the long term intervention.

What about hanging a bag of dopamine for someone who is hypotensive?

why are they hypotensive? the dopamine fixes the hypertension, but stop the dopamine, and the pressure goes back up. so it is a short term intervention, until the underlying cause can be determined, and dealt with using long term interventions.

What about CPAP? If you can give an intervention that drastically affects the rest of the patients treatment for the current disease, is it really short term?

Are they on CPAP for the rest of their life? don't get me wrong, I have seen CPAP do amazing things on CHF patients, and it can be a life saver. but it is a short term lifesaver, until the patient is transported to the ER, and put on long term medication. after all it's not like patients walk out of the ER still attached to cpap machines 24/7.

Are paramedics who give thiamine for ALOC/drunk patients really treating short term illnesses with it?

Got me on this one. I have never seen a paramedic treat someone who was just drunk, to the point of giving medications. ALOC depends on the cause, but for an intox, it's usually a comfy ride to the hospital.

 

[JPINFV]

All of these interventions are short-term with the potential to be utilized long-term. Most are interventions that are begun in the field and very likely to be changed based upon further findings and/or testing. In some cases, they become just the first volley in a juggling act that may or may not help the patient; that's just the way it is.

Sure, they might be changed, adjusted, or what ever, but that doesn't mean that I'd consider them short term if it affects the entire course of treatment. Something like naloxone which might have to be readministered would be short term. Dextrose is short term. However, is dextrose more or less important than the sandwich following it, or do they go hand in hand in definitively treating an episode of hypoglycemia. To me, saying that a paramedic's treatment is only short term treatment sells short the importance of initial diagnosis and management.

My mother had 2 strokes about 15 years ago and spent a significant amount of time in the hospital recovering and rehabilitating. The first month she spent in the ICU. Since that month was a minority of the time she was being treated, was the ICU short term care in the grand scheme of things? If it is, was it any less important than the rest of the time she spent in the hospital?

The goal is to get the patient to a higher level of care, expeditiously, alive and without further harm. Anything else is a bonus.

Does that seem like a reasonable statement of priorities?

Sure... if you want to be a glorified taxi driver. Is the goal of the emergency department making sure people get admitted without harm, or is it to try and improve and stabilize their condition to the best of their ability pending admission?

 

[JPINFV]

The hell? My hands must be disconnected from my brain. I can't remember what my initial example was, but it wasn't supposed to be an AED.