is "ALS" a lie?

[JPINFV]

So... what's the definition of a short term intervention? Is it anything but long term medications or surgery? Would something like antibiotics be considered a short term medication because once the bug is gone, there's no need for bug juice?

 

[firetender]

It can be NOTHING BUT SHORT TERM!

Why? Because our patient exposure is short term...the shortest of the patient's exposures in the scheme of his/her recovery. Our job is to BE short-term.

We are the jump-starters, if you will. We don't replace the battery.

 

[Veneficus]

So... what's the definition of a short term intervention? Is it anything but long term medications or surgery? Would something like antibiotics be considered a short term medication because once the bug is gone, there's no need for bug juice?

But even surgery can be short term.

Palliative surgery for cancer is quite common. Biological heart valve replacements are only meant to last 5 years. (though sometimes you can sqeeze a few more out) A bypass doesn't eradicate coronary artery disease, and for the best example, if you have your pancrease taken out, your trobles are only just starting.

Firetender,

I respectfully do not agree that EMS is a short term solution. Rather I agree that it seems to be but shouldn't be.

EMS is perhaps the last large scale organization of providers who actually walks among the community it serves. It has the potential to be the help people need. Whether it be social, educational, or medical. That help in the front line trench is not something that can be effected by the most skillful surgeons, nor the smartest doctors who reside in the 9-5 offices or the ivory towers of medicine.

Rather than just not making things worse, I think it is past time that US providers step up to the level of their European and Australasian counterparts and truly serve those which fund them, rather than just serving themselves by doing as little as possible by only doing what makes them feel like heroes and playing it off as not having the education, the legal support, or the tools to be more. Laws can be changed, education is available, and I know of at least 1 lawyer who backs EMS providers.

I will give an example.

If a teenage prostitute comes to an STD clinic, and is treated with antibiotics for an STI, and the provider makes a strong case with social services to find her placement (no matter how rudimentary) as well as a meal and some job training, and therapy for alcoholism or addiction, what was the true intervention?

Was the long term therapy the antibiotics, or making the effort to help somebody out of a miserable existence?

They don't teach the non medical therapies in medical school.

 

[Melclin]

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.

I hear this all the time from first aid vollies.

The important issue here though is that without the education that underpins these ideas, its not 15 years of experience, its 1 year repeated 15 times.

I don't care if you've been a first aid volunteer with St Johns for 10 years, it does not trump my bachelors degree and a year of experience when it comes to assessing a patients needs. By that logic you could earn your MD with a hundred years on the job as a CNA.

I went to a job with a first aid volly for a 57 female post syncope/SOB. O/A Pt looks SICK, extensive cardiac history, etc. The FA volly wanted to d/c her from the spot we found her after *drum role*... taking her pulse and finding it to be "normal". We had something of a disagreement about that and it ended up being taken out of my hands (long story). Afterwards, he tells me condescendingly that when I get a bit more experience I will learn that there are some pts that just don't need, as he called it, "excessive interventions" like taking her BP. MI wasn't even on his radar because there was no crushing central chest pain. The mind boggles. If you don't know the difference between syncope of reflex mediated/vasovagal origin, and a massive bloody anterior MI (or even what they are!!), then you don't get to make decisions about a pt who could have either (or a million other things), no matter how many times you've watched someone else do it.

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

I can't stand this idea. A taxi driver with a CPR card (*cough* EMT *cough*) could do this.

One of my favorite examples in the struggle against this idea is falls in the elderly.

Option 1: Turn up lights and sirens, collect dot point information that you don't understand put them on the bed, put them on the monitor & some absurd amount of oxygen, then successfully place an IV on your third attempt (damn labile nanna veins). You take them to hospital and later complain about low pay and boring non-emergency jobs while sitting in the ambulance bay. You turn up every few weeks to the same person who keeps falling and you repeat the same meaningless collection of information, interventions and transports. A few months later you stop going to that person's house. You don't know it but they were moved to high care supported accommodation because of their falls and worsening health, away from their friends and the neighbourhood they've lived in all their life, and 18 depressing months later died of sepsis/community acquired pnemonia.

Option 2: You turn up assess granny, find her to be in the best of health. You don't transport her because your system trusts that you are educated enough to be able to make these decisions. Then you look into why she fell. You know from your education that oldies falling is responsible for a decent slab of injury, reduced quality of life and even death. After a little detective work, you discover that the lip of nanna's rug is catching on her slippers. So you move the rug. From your education, you know that low vision is high on the list of causes of falls in the elderly. You do a quick test of visual acuity and find its sub par. You use an amsler grid (READ: the pts living room blinds) to establish the possibility of age related macular degeneration and organise for her to see her GP as soon as practical. From keeping up on relevant research and health care initiatives instead of re reading your protocols for the millionth time, you remember that a local clinic is trialing a falls referral team so you give them a bell and they are happy to come and assess her the next day. You finish your cup of tea, bid nanna good bye and toddle off home.

I know which one sounds better to me. The list of examples like this is long. Gatro pts are another example. You could take them all to hospital (no doubt Code 3 with 15LPM O2), in the process infecting half the town, or you could risk stratify them and leave some at home after educating them and their family and writing a care plan including antiemetics, hydration/electrolytes and an appropriate medical follow up if necessary. In doing so you reduced the spread of disease, reduce ED work load and prevent an unpleasant and unnecessary few hours in ED for your pt. You may even increase their coping capacity so that when the pts husband has gastro a year later, they don't call an ambulance (probably a long shot ).

None of this stuff is really immediate (or in these cases even involve a trip to ED), but it is still very important and well within the realms of reasonable practice for a well educated (but sans MD) health care provider.

 

[MrBrown]

Oz stop talking sense and come help Brown double-check the dosage of suxamethonium in this chap Brown is about to knock out and intubate on his living room floor.

What? He had the sniffles ....

 

[clibb]

I hear this all the time from first aid vollies.

I don't work for a first aid volly. It's an ALS 911 hospital based company.

 

[TransportJockey]

I don't work for a first aid volly. It's an ALS 911 hospital based company.

EMT-B is about the same level as their first aid vollys

 

[TransportJockey]

I hear this all the time from first aid vollies.

The important issue here though is that without the education that underpins these ideas, its not 15 years of experience, its 1 year repeated 15 times.

I don't care if you've been a first aid volunteer with St Johns for 10 years, it does not trump my bachelors degree and a year of experience when it comes to assessing a patients needs. By that logic you could earn your MD with a hundred years on the job as a CNA.

I went to a job with a first aid volly for a 57 female post syncope/SOB. O/A Pt looks SICK, extensive cardiac history, etc. The FA volly wanted to d/c her from the spot we found her after *drum role*... taking her pulse and finding it to be "normal". We had something of a disagreement about that and it ended up being taken out of my hands (long story). Afterwards, he tells me condescendingly that when I get a bit more experience I will learn that there are some pts that just don't need, as he called it, "excessive interventions" like taking her BP. MI wasn't even on his radar because there was no crushing central chest pain. The mind boggles. If you don't know the difference between syncope of reflex mediated/vasovagal origin, and a massive bloody anterior MI (or even what they are!!), then you don't get to make decisions about a pt who could have either (or a million other things), no matter how many times you've watched someone else do it.



I can't stand this idea. A taxi driver with a CPR card (*cough* EMT *cough*) could do this.

One of my favorite examples in the struggle against this idea is falls in the elderly.

Option 1: Turn up lights and sirens, collect dot point information that you don't understand put them on the bed, put them on the monitor & some absurd amount of oxygen, then successfully place an IV on your third attempt (damn labile nanna veins). You take them to hospital and later complain about low pay and boring non-emergency jobs while sitting in the ambulance bay. You turn up every few weeks to the same person who keeps falling and you repeat the same meaningless collection of information, interventions and transports. A few months later you stop going to that person's house. You don't know it but they were moved to high care supported accommodation because of their falls and worsening health, away from their friends and the neighbourhood they've lived in all their life, and 18 depressing months later died of sepsis/community acquired pnemonia.

Option 2: You turn up assess granny, find her to be in the best of health. You don't transport her because your system trusts that you are educated enough to be able to make these decisions. Then you look into why she fell. You know from your education that oldies falling is responsible for a decent slab of injury, reduced quality of life and even death. After a little detective work, you discover that the lip of nanna's rug is catching on her slippers. So you move the rug. From your education, you know that low vision is high on the list of causes of falls in the elderly. You do a quick test of visual acuity and find its sub par. You use an amsler grid (READ: the pts living room blinds) to establish the possibility of age related macular degeneration and organise for her to see her GP as soon as practical. From keeping up on relevant research and health care initiatives instead of re reading your protocols for the millionth time, you remember that a local clinic is trialing a falls referral team so you give them a bell and they are happy to come and assess her the next day. You finish your cup of tea, bid nanna good bye and toddle off home.

I know which one sounds better to me. The list of examples like this is long. Gatro pts are another example. You could take them all to hospital (no doubt Code 3 with 15LPM O2), in the process infecting half the town, or you could risk stratify them and leave some at home after educating them and their family and writing a care plan including antiemetics, hydration/electrolytes and an appropriate medical follow up if necessary. In doing so you reduced the spread of disease, reduce ED work load and prevent an unpleasant and unnecessary few hours in ED for your pt. You may even increase their coping capacity so that when the pts husband has gastro a year later, they don't call an ambulance (probably a long shot ).

None of this stuff is really immediate (or in these cases even involve a trip to ED), but it is still very important and well within the realms of reasonable practice for a well educated (but sans MD) health care provider.

I know which option sounds better to me too, and unfortunately as long as there are certain types of agencies running the majority of EMS in the US, it'll never happen

 

[usalsfyre]

The problem is not really a particular type of agency, it's that there's no education and more importantly funding for option #2. As long as we only get paid to transport to the ED in the US, that's what will be pushed.

 

[TransportJockey]

The problem is not really a particular type of agency, it's that there's no education and more importantly funding for option #2. As long as we only get paid to transport to the ED in the US, that's what will be pushed.

My experience was that any mention from the state of increased education and that agency pitched a royal fit. That's the main reason I said that.

 

[usalsfyre]

My experience was that any mention from the state of increased education and that agency pitched a royal fit. That's the main reason I said that.

I see what your saying. Even with privates of you can convince competent management (competent EMS managment, there's an oxymoron) that increased education will bring increased reimbursment, you'd have a case. When "keeping brothers employed" is the goal then your sorta screwed.

 

[Veneficus]

I see what your saying. Even with privates of you can convince competent management (competent EMS managment, there's an oxymoron) that increased education will bring increased reimbursment, you'd have a case. When "keeping brothers employed" is the goal then your sorta screwed.

With the amount of people looking for any job, much less a cush job like the fire service, slash the pay by 1/2 and if they want to strike or quit, let them.

We didn't have many problems when Regan came down on air traffic controlers.

 

[TransportJockey]

With the amount of people looking for any job, much less a cush job like the fire service, slash the pay by 1/2 and if they want to strike or quit, let them.

We didn't have many problems when Regan came down on air traffic controlers.

I was gonna make a smartass comment about that... but IIRC it was probably around the time I was being born, if not earlier

 

[MrBrown]

It was 1982 if Captain Brown remembers correctly.

Poor PATCO.

 

[Veneficus]

I was gonna make a smartass comment about that... but IIRC it was probably around the time I was being born, if not earlier

Damn kids

They haven't figured out to beware the old guy because we somehow survived this long and nobody is that lucky.

 

[firetender]

None of this stuff is really immediate (or in these cases even involve a trip to ED), but it is still very important and well within the realms of reasonable practice for a well educated (but sans MD) health care provider.

Mr Brown and Melclin, just for the record, I AGREE with your descriptions of the way things should be and the way they may be over there, but we're in Kansas, NOT Oz!

(I don't know if NZ qualifies as an Ozzie like place, but I'm an American, therefore ignorant of anything but my own back yard; besides, it's a fun metaphor!)

...and we're talking TODAY and not some time in the future when

1) we are trained to have other than tunnel vision, and
2) we are allowed the TIME to be more involved with patient care

That just ain't so right now! So we have to work with what we have UNTIL we get our acts together enough to CHANGE the system we're in.

With the systems in place today, in the U.S., EMS is short-term intervention using either basic or advanced techniques and therapies designed to get the affected person to a higher level of care in part BECAUSE doing much more subjects the systems we are part of and ourselves to liability...and we've got to get to the next call.

We are not really health-care practitioners, we are the lowest end of the totem-pole and essentially just deliver the affected into a SYSTEM. We are the introductory agents; we are SPECIALISTS in a very limited job description that makes us think we do more than load and go, but really, we just do SOME stuff, then load and go.

Let's go back to the original post:

Vene: Perhaps we should stop our focus on education, and focus more on provider attitude?

Perhaps before weeding out the minimally educated, we should weed out the minimally motivated?

Often times the earlier EMS providers didn't have guidelines that were supposed to cover it all. They were given what was deemed adequate info to make a difference, then kicked out without benefit of FTO, or senior guidance to succeed or fail.

This is true, but at the same time we (and I was one of them) were working with a lot of ideas that were not clinically proven, as evidenced by the fact that most of what I used in the mid-1970's has been debunked.

Now, the focus is on sticking to protocols that are believed to improve successful outcomes enough to GET THE AFFECTED PERSON THROUGH THE EMERGENCY AND TO THE FACILITY.

They didn't have benefit of technology, but they somehow saved lives. They didn't have the benefit of research, but somehow managed to cultivate their expert opinions to make a difference. Many didn't exactly "fit in" to society, but then EMS didn't need people who did. They needed free thinkers. People not afraid to take what little they had and make hard choices. They faced the same problems as today. Patients with social issues, medical issues, mental issues, even no issues.

Those providers, like the surgical team weren't advanced because they had some invasive procedures. They were advanced because when the S*** hit the fan, they put their heads together and make something up. Usually more fearful they would fail the patient then get into "trouble" with the boss.

Doesn't EMS still need that?

If not, what is the value of EMS?

Right now, Vene, you are working in a controlled environment. I don't think EMS will change to be anything but getting a person from the scene of their illness or injury; from chaos TO a controlled environment; to YOU. Whatever measures we employ, at best they are initial steps to provide enough stability to get the patient to the next phase of treatment.

The team cooperation you speak of simply is NOT available in the field. As with all professions, it is the renegades that define it, through much trial and error, and the ones coming up in the ranks who execute what was learned. Most often, the risk-takers get burned because in the trying, they lose lives.

One of the things you're missing is that we/they "put their heads together and make something up." but many of those things (Bicarb, Epi, ZAP! Bicarb, EPI, ZAP!) were found to produce poor patient outcomes. Sure, out in the field I believed I really did save a lot of lives (pulseless and apneic converted to rhythm and breathing) but really what I was doing was manufacturing Cardiac Cripples.

...and that was only discovered AFTER they were part of the larger system designed to administer care within a broader spectrum.

The defining structure -- corporate, litigation-driven, institutionalized, for profit -- has carved out a small niche for the EMS provider to work in, and he or she works in it only TO THE EXTENT THAT IT SERVES THE LARGER STRUCTURE.

You'll notice that I'm not talking too much about the actual needs of the human being involved, the patient. It's all about intervention within narrowly-defined parameters.

Maybe ALS is not the issue.

 

[usalsfyre]

The system is absoloutely the issue here. Most of my scenes aren't any more chaotic than the ED, most of them are actually far less so. I would easily have enough time to assess and dispo a patient, especially if I didn't have to tote them to a facility 30-50min away for a minor complaint because they don't like/have nearly been killed by the meatheads at the local veterinary facility. The problem is, most paramedics aren't educated to tell the difference between what needs to be seen/can be discharged, many of them don't care to learn because it's not "saving lives" and most importantly, my company can't get paid if I don't transport.

The game changer will be who figures out how to get reimbursed at a higher rate (but still much lower cost than an ED visit) for taking care of these minor medical issues.

 

[Melclin]

...and we're talking TODAY and not some time in the future when

....

That just ain't so right now! So we have to work with what we have UNTIL we get our acts together enough to CHANGE the system we're in.

....

Right now, Vene, you are working in a controlled environment. I don't think EMS will change to be anything but getting a person from the scene of their illness or injury; from chaos TO a controlled environment; to YOU.

....

The team cooperation you speak of simply is NOT available in the field.

Fair enough. I think its important though to clearly define that though. If you argue against the idea of EMS in America being more, you've gotta be clear that you're simply talking about the definition as it stands currently and not what it should be. The thread after all is about what EMS should be doing. Our system isn't quite universally up to the level I described in our options either (It depends on the paramedic's preferences). But I'm describing things how I think they should be. Still, I suppose its quite reasonable to argue that the OP has unreasonably high expectations for the current system given its role, which I suppose is essentially what you were saying.

I'm not sold on the idea of uncontrolled environments. I've worked at rock concerts where you pick a kid up from the mosh pit with a spinal injury or a MVA with car whizing around but those jobs and of course you're not going to get to be too thorough in those environments, but they are in the minority. Mostly we go to +65s with miscellaneous complaints that get mistaken through dispatch as CP, SOB or hemorrhage (which is why I never really got the exclusively American concept of "street EMS" or "street medicine" - it sounds so tough, like we bounce around with our hommies patching up gun shots with steely expressions). Many of our jobs involve sitting on a pleasant floral patterned sofa and chatting to sick old person #49856. I agree with usalsfyre, its mostly pretty controlled.


Just on a side note, does anybody do care plans when they don't transport patients? I don't necessarily mean a formal multi-page document, but some form of clear plan of action for them. If so what form does it take? Do you/are there legal issues with recommending drugs?

 

[clibb]

I love this line that I heard from a medic once, "If EMS would strike for 7 minutes all over the US at the same time. Everything would go to hell and we'd get the pay we want."

 

[MrBrown]

I love this line that I heard from a medic once, "If EMS would strike for 7 minutes all over the US at the same time. Everything would go to hell and we'd get the pay we want."

Cool story bro, not.

What do you think causes low pay?