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9/22/2017 12:11:25 AM
Posted: 6/5/2003 5:07:40 PM EDT
[Last Edit: 6/5/2003 5:12:51 PM EDT by Ohio]
No one denies that training has changed. Experts in the field say that the changes are for the better, by eliminating unneeded "nice to know" stuff no one (well, few) remembers anyway. I take no stand; I don't consider myself expert enough to judge MDs with advanced degrees in Emergency Medicine. --subject shift-- Most Basics out there have enough troubles; We as a general rule, don't want the added requirements; I don't want to push drugs or interpret rythyms; frankly I don't run consistently or often enough on our county squad to stay up on any advanced skills. We get maybe one cardiac run a month; that's not enough to stay competent. I am an EMT-B in Ohio; we use preloaded Epi pens and nitro spray. I'm good with that. I DO, however, want to keep Epi, nitro, and glocometers. These are things that help immensely and immediately; and are really hard to hurt someone with if you remember an *easy* protocol. I personally can give IM and SQ injections quite competently; I am an amateur vet working on dogs and goats for the most part. I don't want to load syringes in a hurry on people, as I fear getting rattled as I wouldn't do it more than every couple months and I don't trust myself to do the math.
I really do appreciate you and your service as a volunteer EMT-B.
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I thank you for that. One more thing:
wiggy762 Are you seriously suggesting that EVERYONE that can sign up for a class, struggle through and pass the state exam should be given the authority to admin drugs to your family?
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Is pretty much a definition of how one becomes a nurse, doctor, or paramedic as well; so I suppose so. Larry
Link Posted: 6/5/2003 6:07:57 PM EDT
Larry, Saw your reply in that 'other' thread and came over here to say Hi. Hi. I am worried about the continued escalation of expected skills at ALL LEVELS of EMS, if there is not a commensurate increase in training. I have posted a few examples and have been villifed for being a Para-God, but believe me, I had the same opinion when I was a basic. I was one of those rare finds that ran for two years as a full time paid Basic EMT. Without boring you to tears, I have seen the elephant when it come to EMS. Have I seen it all? Of course not, but I have seen enough to speak knowledgeably. After saying all of that, I do not have a solution. I will continue to train poorly equipped EMT-B's as they come to my crew in an effort to complete what their classes started.
Link Posted: 6/5/2003 6:17:20 PM EDT
Originally Posted By Ohio: One more thing:
wiggy762 Are you seriously suggesting that EVERYONE that can sign up for a class, struggle through and pass the state exam should be given the authority to admin drugs to your family?
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Is pretty much a definition of how one becomes a nurse, doctor, or paramedic as well; so I suppose so. Larry
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My statement here is vague, I'll grant you that, but in context, it was referring to the mouthbreathers comments that ruffled a few feathers. Let me try to be more clear; Do you want an under-trained individual, with no other medical training, posessing the ability to administer drugs (not auto-inject or Pt. assist) to your family members in the following case; 1. without the benefit of advanced monitoring capabilities to be able to quickly and surely determine if there is a deadly reaction occuring. 2. without IV access to administer an antidote or an antagonist in the case of an extreme bad reaction. 3. without a proper understanding of the Parmacologic effect of the drug in order to be able to quickly counteract it. 4. without the adequate training and equipment to be able to save a Pt. post administration in the event of a bad reaction. That was the full intent of my statement. As you can see it was directed at EMT-B's or any other non-ALS trained person that is given the power to administer meds without the training or equipment.
Link Posted: 6/5/2003 6:55:48 PM EDT
ALS = Goldlike BLS = You call we haul
Link Posted: 6/5/2003 6:58:34 PM EDT
This entire topic has been betting to death. Ain't no way wiggy762 will ever change his mind that us "mouthbreathers" deserve to be EMT's using the skills we learned in class. Sure you need further edjucation & teaching's to enhance our "basic" skills but then again that's why it's called basic. We have way more training than the average person & have the ability to stablize a person and to prehaps keep them alive using the ABC's till a ALS rig arrives on scene & takes over. so what if I can't give a IV. If you're wife is having a MI & needs nitro & O2 to help stablize her & keep her alive till we either get to a hospital or a ALS rig arrives then we have done our job. I've only been a EMT-B since Jan & thus according to wiggy762 a stupid dumded down EMT. My measly 160 hours can't compare to his thousands of hours let alone my few PT contacts compared to his thousands. I know my training is at the bottom rung of the EMS ladder but also know my limits & knowledge base. Sure I need more training but so do even the para gods. Bottom line is if the NREMT who sets the standards gives you a card then you have passed the course and then you're state certs you you better be able to put into practice everything you learned. Course thas why we have to have CE hours also eh??? The training never stops. Now if wiggy wants to do something other than bitch and moan & insult every EMT-B here he needs to take his soapbox to those who set the standards. Contact NREMT & you're state EMS agency and see if you can become part of the solution or if you are just part of the problem & making things worsse.
Link Posted: 6/7/2003 6:30:18 PM EDT
Problem Statement: The basic EMS protocol is insufficient in many cases to handle emergencies requiring immediate intervention. Problem Statement: Raising the level of care without commensurately raising the level of training may cause as many problems as it addresses. What the EMS gurus need to quantify and put into place the interventions such as drugs and items like AED that CAN be safely used without needing the monitoring and antagonists such as you mention. Package them in such a way, and craft the protocols and use of medical control, so that they are good to go for a person with the level of instruction of a current EMT-B. This is what I like about the Epi, AED, spray nito, glucometers/glucose, and probably something else I forget. We have been trained in intubation, but we are only allowed to use it if the person is (as far as we can tell) asystole. That way we do not damage an otherwise viable pt., but we may be able to help one that is in this condition. Now, what I ask from you; is whether or not there is a way to use/deliver cardiac drugs similarly: Is there a way to differentiate a pt that is otherwise viable from one that "Hey, it can't hurt", before it's too late? There is a very, very grave and insurmountable reason that they cannot raise the basic training too far, in terms of hours, difficulty, and cost. The reason has already shown itself in rural departments with the intubation/nitro/epi additions; that we lose volunteers everytime we raise the training or complicate the protocol. [b]Question[/b] Do I want people with minimal training, no clear idea of what they are causing, and no way to undo (antagonists) the act giving drugs to my family? [b]Answer[/b] No, if there is someone better to administer; but [b][i]YES[/b][/i] if the alternative is to simply watch them pass away unhelped. I would let a farmer hit my kids with vet supply epi before I "took the high road" and refused out-of-scope care by an untrained individual. Your thoughts? Enough for now, sorry for the delay. Larry
Link Posted: 6/9/2003 8:53:23 AM EDT
[Last Edit: 6/9/2003 8:56:52 AM EDT by wiggy762]
Originally Posted By Ohio: Problem Statement: The basic EMS protocol is insufficient in many cases to handle emergencies requiring immediate intervention.
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Great statement. I think the main cause of this is the thought that MOST EMT-B's will be partnered up with a Paramedic and as such, do not need the training to be able to run an entire call without any ALS assist. I think that none of the pepole that write the criteria are from a rural or volunteer BLS background.
Problem Statement: Raising the level of care without commensurately raising the level of training may cause as many problems as it addresses.
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Another great statement. The root cause of this is the perception that the training a Basic EMT receives in class will be 'finished' at their service. Once again, this assumes that the Basic's will not be running on their own at the end of the state testing.
What the EMS gurus need to quantify and put into place the interventions such as drugs and items like AED that CAN be safely used without needing the monitoring and antagonists such as you mention. Package them in such a way, and craft the protocols and use of medical control, so that they are good to go for a person with the level of instruction of a current EMT-B. This is what I like about the Epi, AED, spray nito, glucometers/glucose, and probably something else I forget. We have been trained in intubation, but we are only allowed to use it if the person is (as far as we can tell) asystole. That way we do not damage an otherwise viable pt., but we may be able to help one that is in this condition. Now, what I ask from you; is whether or not there is a way to use/deliver cardiac drugs similarly: Is there a way to differentiate a pt that is otherwise viable from one that "Hey, it can't hurt", before it's too late?
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You ask a great question, and the answer will not be as great, I'm sorry.[:D] In the ALS field, there are drugs that are considered 'benign' and as such will not cause any harm to the Pt. under normal doses. These are typically Dextrose 50%, and Narcan, some agencies have standing orders to administer a 'coma cocktail' containing these drugs to all unconscious unknown Pts. The thought is that if the Pt is unresponsivedue due to hypoglycemia or narcotic OD, these drugs will treat these conditions and if the etiology of the unresponsiveness is due to another cause, these drugs will not hurt the Pt. Unfortunately, there is less commonality once you get too far away from these drugs or adjuncts. IIRC, for example, if a Pt has Pheochromocytoma (a disease of the adrenal glands), administration of Epi could be fatal. For another example, if an AED is applied to an arrhythmia of SVT, the computer could mistakenly ID this as a pulseless V-tach and shock a pulsatile rhythm into asystole. Admittedly, the chances for occurance of these examples are slim, but if the relaxed standards cause ONE untimely death, the price is already too high. It seems that the EMS gurus are willing to forgoe these occurances IF they can churn out more EMT's for use in the big services. The gurus are hanging the rural and volunteer Basic's out to dry.
There is a very, very grave and insurmountable reason that they cannot raise the basic training too far, in terms of hours, difficulty, and cost. The reason has already shown itself in rural departments with the intubation/nitro/epi additions; that we lose volunteers everytime we raise the training or complicate the protocol.
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EXACTLY! The large metro services, most being for profit, are interested in basic's only as drivers. The reason is money as insurance companies and Medicare/Medicaid will pay a higher dollar amount for an ALS call than for a BLS call. These services (I was a Paramedic with one) will then put a Medic on each rig to be able to charge the ALS fee IF the Paramedic runs the call. These sercives will get a much lowered reimbursement if the call is BLS or if the Basic runs the call. The EMS gurus are toadying up for the bigger services at the expense of the rural, volunteer or BLS services.
[b]Question[/b] Do I want people with minimal training, no clear idea of what they are causing, and no way to undo (antagonists) the act giving drugs to my family? [b]Answer[/b] No, if there is someone better to administer; but [b][i]YES[/b][/i] if the alternative is to simply watch them pass away unhelped. I would let a farmer hit my kids with vet supply epi before I "took the high road" and refused out-of-scope care by an untrained individual. Your thoughts?
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Good question and I'll agree with you in this instance, but would your answer change if there was underlying etiology such as trauma? If a family member was experiencing an AMI and fell down incurring a Fx of the R midshaft radius/ulna. I DO NOT want the trauma treated at the expense of the AMI. The classes I have been involved with have done (in my opinion) a poor job of preparing the Basic for actually running calls as the lead tech. My current Basic class has even indicated that the training needed to actually run a call will come from your final service. I agree that we should not be burdening our new Basic's with unneeded information, BUT I was sure glad to have this unneeeded information when I was running calls all by myself just 1 week after taking the state test. And I was even more grateful I had the unneeded info as I went further in my training. The maxim I really like is that Paramedics save lives (not very often though) and EMT-B's save Paramedics (happens all the time). This is true because the nuts and bolts of Pt. care is not ALS, but rather BLS and is the backbone of Pt care. It is this backbone that the EMS gurus are threatening by reducing or outright eliminating these "unneeded but nice to know", vitally important items. Pt care WILL suffer if this trend is not reversed.
Enough for now, sorry for the delay. Larry
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No problem, but I am enjoying the discussion.
Link Posted: 6/13/2003 4:58:01 PM EDT
Originally Posted By wiggy762: I think the main cause of this is the thought that MOST EMT-B's will be partnered up with a Paramedic and as such, do not need the training to be able to run an entire call without any ALS assist. I think that none of the pepole that write the criteria are from a rural or volunteer BLS background.
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Now here is something that I have always wondered, especially with the recent onflation of skills. The DOT or whomever takes this over needs to realize that not everyone can provide services like a municipal department. here in our county we have had two paid services; one was the city of Bellefontaine, the other a simple squad around a resort area. The city has all FF/Medics. All runs have medics; though they will hire a basic he has to get his medic at the local college within a certain time frame or he is out. During his training they will run three-man. The Lake has whatever they can; they have to run Medic a percentage of the time, and at peak times. Otherwise it could be two people right out of class. In the volunteer departments we run whoever shows; I *have* been on runs where the only people showing had less than two months service (I was one), and neither of us newbies felt secure enough to call for medic backup from town. It all worked out, but it was a little puckery.
Another great statement. The root cause of this is the perception that the training a Basic EMT receives in class will be 'finished' at their service. Once again, this assumes that the Basic's will not be running on their own at the end of the state testing.
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Which is valid in most muicipal departments. Not in rural and paid-for-profit services (different in character than "paid-volunteers")
Admittedly, the chances for occurance of these examples are slim, but if the relaxed standards cause ONE untimely death, the price is already too high.
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Ohh Noo! Sorry, but I have to violently disagree; you are using the wrong algorithm. Properly, if the relaxed standards cause one more death [b] than the previous standards[/b] would have, the price is too high. If they kill one person, but allow five lives to be saved because the treatment is [b] usually[/b] benign, they are good.
It seems that the EMS gurus are willing to forgoe these occurances IF they can churn out more EMT's for use in the big services. The gurus are hanging the rural and volunteer Basic's out to dry.
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Yep. We need to hire 24/7 if we are supposed to have a guaranteed response. We simply cannot afford it when we have maybe five runs a week; only one of which is a medic call (averages). Absolutely preposterous. Now, we can always call on Bellefontaine; and if the medic is available they will come out. It takes maybe 20 minutes to get to most of our district, tops. Basic intervention will be OK in most situations until then. BUT, if Bellefontaine has a big fire or emergency, and they then call in their off-duty people; not only are they no longer available, they have also pulled half of our medics in as they work there. We need a copius supply of basics; so we can at least load and go with CPR. It's far worse for my brother in W. Va., but I'll leave that for now. (>45 min. for ambulance response!)
EXACTLY! The large metro services, most being for profit, are interested in basic's only as drivers.
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Snipped a long and depressingly true story.
I DO NOT want the trauma treated at the expense of the AMI. The classes I have been involved with have done (in my opinion) a poor job of preparing the Basic for actually running calls as the lead tech. My current Basic class has even indicated that the training needed to actually run a call will come from your final service.
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But what is the solution? In much of America today the choice is between people with no ability with a 12-lead, and no idea what the lines mean, or [b]no people at all[/b] if the standard of care is set too high. At least someone showed up; some days you may wait for third call before a dept. gets a crew. Raising the standards too high makes this worse. Fast and low level is better than waiting for a medic squad from far away. A different focus, that's the answer. We need to be able to send band-aid and splint guys that have that drill down {b] real freakin' good[/b]. First Responders we call them in Ohio. This is in flux; I don't kow where this is going. Then what we call Basic for anything up to where we are, but not too far to scare people. Train us [b] when to call for help[/b], a focus entirely missing from the curriculum. Package some more drugs for us; ones that help more often than hurt. The problem with the "nice to know" stuff is that it displaces training that otherwise might go on. I really like NTK stuff, and have learned a lot on my own and apart from the EMS trade. I would rather see the time spent training people fully at their expected level of activity, then making hte other training available either as an upgrade, or as continuing ed (most of which is a waste of time). It sounds like I am changing my mind a lot, but not really. I want the people to have their training solid in whatever level they will be serving, but let's get people on the street in the volunteer departments as quickly as possible! THEN let's upgrade them as best we can, using canned drug regimens and such. Maybe a real benefit would be realized to have a different "for pay" standard apart from the volunteer standard. They do in firefighting. That way they could get well-trained people out in the world for us volunteers, and have a different level of training for medi-taxis. I dunno. Larry
Link Posted: 6/16/2003 6:53:55 AM EDT
This was the absolutely best thread on EMS I have seen. You have pulled all of the different issues into a concise statement or two. I thoroughly enjoyed reading it and I think that your possible solution is the direction EMS needs to take if they are going to fix this.
Link Posted: 6/19/2003 2:07:33 PM EDT
[Last Edit: 6/19/2003 2:12:35 PM EDT by Garand_Shooter]
Link Posted: 6/19/2003 4:35:54 PM EDT
In Ohio there are several distinct and separate things we call EMS. 1. Municipal Departments: Fire/EMS, usually the same guys that respond to any call; what they drive depends on the percieved needs of the department. Very few areas have separate Fire and EMS departments. The few I know of are only separate because they have different tax bases. Most of these are 100% Paramedic. They are different from the next group by the fact that their people are Full-Time; usually 24/48 hour shifting. Haz-Mat Operations at minimum. 2. Paid Professional, Part Time Often townships (rural) or small town, these hire gypsy EMT/Medics to staff by stand-by rather than on call. They usually run Medic level, though usually only have one medic per truck. Usually very professional attitude and standards. 3. Paid Amateur Rural, an evolution of Volunteer EMS. they pay their people per-run; usually they have a schedule of who will be "around" when they page out; but it's not a hard "on-call". Some will be on "home-standby", a few actually do a "station-standby". A mix of training; no guarantees. Not neccesarily Medic capable at any given time. 4. Pure Volunteer My squad. Whatever we can get people to train to; training may or may not be covered by the Township, depends on budgets and attitudes. You never know who is going to show, or what level you are going to run. No compensation at all. No schedules, no stand-by, if no-one responds 4600 calls the next squad in line, which could be any of the above or below types, depending on where you are and what's going down. We often run as a basic squad. 5. "Medical Taxis" They hate the term, but I'm trying to be honest. Every area has a "transport service" that does transfers and such; contracts to nursing facilities may make them first call. Some even contract with Counties for EMS, either first call or backup. They do standbys at Fairs and such. They hire a lot of Basics; they try not to tie up expensive Medics for a basic run; if there aren't any fluids hanging or a monitor needed they go basic. In W.Va where me brudder lives, he is a volunteer on the FD. They run "crash trucks", extrication/First Response trucks to any call for medical help; all the ambulances come from the county hospital; it may be a 50 minute run just to the scene for the ambulance on a good day, to some places. The place I used to live would be a 45 minute minimum response time, even for a first responder truck. Nice, eh? They usually run flat basic also; training is sparse. Larry
Link Posted: 6/20/2003 5:56:00 AM EDT
There are still places that will hire fulltime Basics to staff the rigs, but you really have to get rural in order to find them and most are way out west in spasely populated areas. The remainder is just like Ohio indicated with a predominant lean towards either staffing at an ALS level with First Responder FD types as initial call out. The primary driver fo this is money as insurance companies and Medicare/Medicaid will pay more for an ALS call than for the same call run by a basic. More money coming in is an irresistable pull for these yahoos running services as they want the bigger bucks for the same call. In order to get the increased money, they needed more Medics or I's to staff these calls so they called their good buddies at the state EMS boards and in Washington at the DOT and asked to have the medic training requirements shortened. While they were at it, they decided to shorten the basics skills requirements also, they were thinking that all basics were going to be on calls with Medics or I's. right? So we are now left with a set of skills requirements that were adopted, not to better provide medical care to our sick and injured patients, but to be able to make more money. Thankfully as far as Medics are concerned, their service takes over as a trainer and gets them up to speed quickly as they are needed to run these ALS calls ASAP in order to keep that Medicare/Medicaid money coming. The techs that get left out are the Basics that are taking a class to be able to better help their families and maybe run a few calls a month in a reserve or volunteer capacity. These basics are only givin their final training if they happen to go to work for a full time agency that is willing to train them in a class environment. In reality, most of these Basics are only trained by the medics they happen to be partnered with at the time. How is this the right and best way to train the most important link in the EMS chain? The trining should be made MORE difficult, not less. We should be weeding out basics through class requirements but instead we water down the requirements, get rid of the 'nice to knows' and then (I really cannot beleive this) include pharmacology! The student is not to blame for this and I am not getting on Basics at all. The training needs to be increased rather than watered down in an effort to get new Basics the required skills and training to run a call completely on their own. Basics need to be taught, in class, basics of Emergency driving, radio comms, scene set-up and the myriad of other things needed to runa call well. Train our new basics to a higher level of self sufficiency so they can take care of a Pt without some Medic making every single decision on every single call.
Link Posted: 6/20/2003 9:28:52 AM EDT
Link Posted: 6/20/2003 10:56:20 AM EDT
Around here, most squads run on local protocols that are copies of the County protocols, which are basically copies of the suggested state protocols. It is a rare MD that will go against the received wisdom of the State Experts. VERY little variation between squads.
Link Posted: 6/20/2003 11:02:17 AM EDT
Link Posted: 6/26/2003 8:27:49 AM EDT
[Last Edit: 6/26/2003 8:29:16 AM EDT by madmedic]
The trend in large fire/rescue departments is starting to lean toward all personnel being paramedics. Our hiring policy recently changed so that all new hires must promise to go to paramedic school (paid for by the dept) within 3 years of hire date. Currently we run 15 rescue trucks (ambulances) with at least 1 medic. The second crewmember can be an EMT, or medic depending on staffing. 13 of our engines are BLS, and 2 are ALS. (My station has a rescue, ALS engine, and a brush truck.) Our protocols are fairly aggressive (medics have a pretty much "free reign" as far as treatment, and procedures)...and EMTs are allowed to start IVs, and intubate. I know which EMTs I can trust to start lines for me, and which ones are better off handling other duties (I have never let an EMT sink a tube, and none have ever expressed the desire to do so...although there are definitely some that I know would do just fine) We have a training program to enhance what the EMTs are taught in class...And I ([i]as well as most other medics[/i]) am perfectly willing to help out with some on the job training. Most of the guys who ride with me know pretty much everything Im going to do on most runs (because they have been involved in it so many times before) We run [b]alot[/b] of ALS calls...and good EMTs to help get everything done before we pull up to the hospital are greatly appreciated.
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