Your Controversial EMS-Related Opinion

[FiremanMike]

Too many egos. LACFD is one good example. Why have seven people on the scene when only a few can actually process the actions needed. The rest are just bodies. I’ve watched paramedics argue about who was more qualified to handle a call. Too many cooks. Hell. Ask a group of seven paramedics which airway adjunct is best, and you’ll have 7 different opinions…

That’s a system problem that has nothing to do with what certification level each person has.

Here, the guy in the passenger side of the medic is writing the report and in charge of patient care.

 

[FiremanMike]

If you have seven medics on one call, what happens when if three more calls come in at the same time?

There is no shortage of paramedics around here..

 

[FiremanMike]

Ok I got one, in the theme of where this conversation has gone..

Tiered systems are only better for lazy medics who wish to passively improve their craft through ALS run volume instead of actively seeking out training and educational opportunities to broaden their horizon.

Some people have 25 years of experience, others have 1 year of experience 25 times.

 

[EpiEMS]

Ok I got one, in the theme of where this conversation has gone..

Tiered systems are only better for lazy medics who wish to passively improve their craft through ALS run volume instead of actively seeking out training and educational opportunities to broaden their horizon.

Some people have 25 years of experience, others have 1 year of experience 25 times.

How would you address the counterpoint that volume of skill utilization improves proficiency?

 

[jgmedic]

That’s a system problem that has nothing to do with what certification level each person has.

Here, the guy in the passenger side of the medic is writing the report and in charge of patient care.

Just wanted to bold this truth.

 

[FiremanMike]

How would you address the counterpoint that volume of skill utilization improves proficiency?

I could never in good conscious advocate for reducing the level of care provided in order to increase proficiency in psychomotor skills..

I think it’s time to quantify the claim that medics in als only systems are weaker than those in tiered systems or move on from it.

 

[Tigger]

Too many egos. LACFD is one good example. Why have seven people on the scene when only a few can actually process the actions needed. The rest are just bodies. I’ve watched paramedics argue about who was more qualified to handle a call. Too many cooks. Hell. Ask a group of seven paramedics which airway adjunct is best, and you’ll have 7 different opinions…

So how does this contribute to scene delays, again?

 

[PotatoMedic]

To be fair I haven't dug into this much, but BLS has better outcomes than ALS (per a study done in 2015)

ACP Journals

Now to try to find the full article.

 

[StCEMT]

I could never in good conscious advocate for reducing the level of care provided in order to increase proficiency in psychomotor skills..

I think it’s time to quantify the claim that medics in als only systems are weaker than those in tiered systems or move on from it.

You're not necessarily reducing the level of care if it's staffed right. I am not needed in the slightest for the lady who had a bug in her ear. Literally any person with a driver's license could do just as good as me.

Besides, how is this concept that different from resource allocation when to comes to MD/DO vs PA/NP use? The hospitals I'm used to working with aren't ever really having the PA wait for us with the high acuity patients, it's the docs.

 

[EpiEMS]

To be fair I haven't dug into this much, but BLS has better outcomes than ALS (per a study done in 2015)

ACP Journals

Now to try to find the full article.

This study was panned but I think it picks up on a broad truth that there is a paucity of evidence in favor of widespread ALS for survival & morbidity outcomes. OPALS is still the best we’ve got (I am inclined to believe, anyway). If you include other metrics like pain control, etc. which do matter but are probably understudied, ALS looks more attractive.

 

[E tank]

This study was panned....

by whom and where? The letters to the editor in the publishing journal only offered criticism focused on analysis methods and study design, both of which are legitimate prudential decisions of investigators. Clearly, conclusions can be called into question when these elements are misapplied to data, but it isn't as though these investigator's methods were resulting in radically off the beam findings....ie...they could very well be right and their conclusions have been suspected for some time...

 

[EpiEMS]

by whom and where? The letters to the editor in the publishing journal only offered criticism focused on analysis methods and study design, both of which are legitimate prudential decisions of investigators. Clearly, conclusions can be called into question when these elements are misapplied to data, but it isn't as though these investigator's methods were resulting in radically off the beam findings....ie...they could very well be right and their conclusions have been suspected for some time...

Not saying I disagree with the conclusions but I do have methodological questions, which really just means we need to be doing research at a better level of evidence (RCTs?).

Some of the feedback - seems like mainly physicians? - was what I was referencing:

Study: BLS patients have higher rates of survival than ALS ones

Research found that the patient population studied were more likely to survive if transported in a BLS ambulance rather than an ALS one

www.ems1.com

Advanced Life Support Takes Another Hit, But Is It a Fair Fight? | Emergency Physicians Monthly

Another JAMA study claims ALS beats BLS. But while it raises important questions, this study has too many biases to form concrete conclusions. “Patients who are having a heart attack, stroke or other serious health emergency have a greater chance of surviving if they’re taken to the hospital in...

epmonthly.com

 

[MackTheKnife]

Meanwhile here a code gets a single Fire company and single Ambulance. If the ambulance is one of the two BLS rigs, they'll also send one of the two medic Rapid Response suvs (or if they're the closest unit). So that's at the most, 3 medics, usually just one, maybe 2 normally.

This is the problem with staffing. You don't dumb down, you smart up. A medic and an EMT on a bus, etc.

 

[CCCSD]

by whom and where? The letters to the editor in the publishing journal only offered criticism focused on analysis methods and study design, both of which are legitimate prudential decisions of investigators. Clearly, conclusions can be called into question when these elements are misapplied to data, but it isn't as though these investigator's methods were resulting in radically off the beam findings....ie...they could very well be right and their conclusions have been suspected for some time...

By paramedics…

 

[E tank]

@EpiEMS ...thanks...a few thoughts (worth less than $0.02)

"Their premise is flawed," said Howard Mell, a spokesman for the American College of Emergency Physicians and director of emergency services in Iredell County, N.C. He said ALS ambulances transport much more serious patients. "That's why they have much worse outcomes."
My nomination for most clueless spokesman of 2015....was he really told that the study was randomized between ALS and BLS transports? As if a system with ALS units sitting around will just send BLS units on calls to see if their patients do better?

As an observational study, it allows for correlations to be made with the data, but it cannot lead to conclusions of causality.
Doesn't mean conclusions can't be drawn from the data, otherwise observational studies wouldn't be published in journals like AIM. And with an n well exceeding a quarter million (approaching a half million), the shortcomings of observational data are pretty meaningfully mitigated.

With regard to selection bias:
The applicability of the results is therefore limited to patients who are in the Medicare system and are therefore generally 65 or older.
The very population most vulnerable to 3 of the 4 inclusion criteria and the largest, most frequently presenting fragile patient population. That is not a study flaw. That's the representative group you want to pay attention to. The study would have been far less meaningful if it were limited to AAA baseball players less than 24 years old...hard to understand the criticism there.

I could go on, but this was a good paper as observational studies go. What this type of study and the tons before it don't (can't) take into account is what the hospitals are capable of providing.

That care advances orders of magnitude faster than what pre-hospital care can is a big confounder. As hospital care becomes more sophisticated, pre-hospital care becomes proportionally less important (not unimportant). Rural areas with less sophisticated hospital capability depend far more on ALS than urban centers do. Add prolonged travel times and it's a slam dunk for ALS. The irony is that those 'underserved' areas are greatly volunteer BLS so the point is moot.

As far as RCT's, I'd be hard pressed to come up with a design that could ethically study this issue that way.

 

[FiremanMike]

You're not necessarily reducing the level of care if it's staffed right. I am not needed in the slightest for the lady who had a bug in her ear. Literally any person with a driver's license could do just as good as me.

Besides, how is this concept that different from resource allocation when to comes to MD/DO vs PA/NP use? The hospitals I'm used to working with aren't ever really having the PA wait for us with the high acuity patients, it's the docs.

I don't think EMT to Paramedic is the same comparison as PA/NP to MD/DO.

As to your other point, true BLS runs don't need a paramedic, but on the same token I think far too many runs are blown of as BLS that really aren't..

 

[StCEMT]

I don't think EMT to Paramedic is the same comparison as PA/NP to MD/DO.

As to your other point, true BLS runs don't need a paramedic, but on the same token I think far too many runs are blown of as BLS that really aren't..

The concept is the same. The higher level provider deals with the higher acuity patient. How it's applied differs, but the overall idea is the same.

That's not a failure of the idea though, it's a failure of how it is applied.

 

[FiremanMike]

The concept is the same. The higher level provider deals with the higher acuity patient. How it's applied differs, but the overall idea is the same.

That's not a failure of the idea though, it's a failure of how it is applied.

Yes, but NPs and PAs have significantly more training and would be more likely to recognize when something is moving past their expertise. Given the current state of EMT-Basic education, I'm not sure that applies there.

I'd assert that it's still ultimately a decrease in level of service, because in a tiered system there can and will be delays in getting ALS providers on scene, where-as in an all ALS system, the first truck on the scene would be able to assess and treat at the ALS level..

 

[DrParasite]

I'd assert that it's still ultimately a decrease in level of service, because in a tiered system there can and will be delays in getting ALS providers on scene, where-as in an all ALS system, the first truck on the scene would be able to assess and treat at the ALS level..

I've said it before, and I'll say it again: based on everything you have said about your department, your agency is likely in the minority when it comes to EMS providers who ride the BRT, and that's a good thing.

The last time I was part of an ALS FD was almost 20 years ago, and all of our FF/PMs had years of experience on the ambulance as PMs, usually as Senior PMs or FTOs. Many still worked for the City's EMS agency part time. Since then, I've worked with a few FF/PMs, but almost all had previous PM experience on the ambulance, and most were function as EMTs or AEMTs when on the BRT.

I know I'm biased, but there are not many suppression only EMTs, who have never worked on an ambulance, that I would trust do provide a decent assessment on a sick patient. There are even fewer suppression only paramedics, who have never worked on an ambulance, that I would feel comfortable assessing and treating at the ALS level, especially on a sick patient, if they were my family member.

I am much happier having the people on the BRTs being decent EMTs, with the ambulance people being more competent and experienced EMTs, along with a paramedic either on the truck or on a flycar, only handling ALS criteria patients.

Think of if this way: if you are putting 7-9 paramedics on a cardiac arrest, do you trust all of them to intubate the 400 lb patient with a mallampati class 3 airway, at 3 in the morning? And when was the last they those 7 to 9 paramedics intubated a live person with a difficult airway? or ran point on a circling the drain patient?

 

[MackTheKnife]

The concept is the same. The higher level provider deals with the higher acuity patient. How it's applied differs, but the overall idea is the same.

That's not a failure of the idea though, it's a failure of how it is applied.

Not true necessarily in the ED. Our NPs and PAs hit the high acuities.