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Again, this is an issue of education. The principle behind the idea of "BLS before ALS" is solid- you must master the building blocks and basic understanding of what you're working with before you move on to more advanced ideas and practices. The problem is that our education is not structured correctly. You are given the wrong building blocks at the BLS level and with that a false understanding of medicine. It is MUCH more important to understand the biology of medicine than it is to understand how to use a BVM or apply a LSB. Your patient history is one of your most important assessment tools, and if you don't have the correct understanding to inform how you go about your line of questioning, you're simply muddling around and missing the point. Anyone can be trained to master the physical skills of medicine... whether it's IV's, intubation, cardiac monitor placement... not everyone has the capacity to figure out how it all fits together at the level which allows you to make sound treatment decisions. I will, however, say that once you master the intellectual part of it you must also master the physical skills... because knowing what's wrong does you no good if you're incapable of performing the right actions to treat it. BUT! Without the correct thinking, all the skills in the world are useless to you. Wendy CO EMT-B

Sorry mate, but you're bullshit. Your poor spelling and atrotious grammar are just wrong. ALS is not "hard" maybe because you don't need any actual education in the United States to practice as an ALS level Officer you find it difficult. Look at why frusemide is being pulled off trucks, why standing orders in Los Angeles are two pages and why you still have "medical command" and practice piss poor remote control medicine in your part of the world. You can write down on ONE SIDE of A4 what you need to do for a cardiac arrest; ask the resuscitation council they have done it. Doesn't mean it's "easy" it takes "skill" but very little "knowledge". Now, try to write down on ONE SIDE of A4 the treatment and management flow-chart for a patient who presents with undifferentiated abdominal pain. Sorry to say, acute stuff like cardiac arrests and intubation is easy, it takes SKILL but very little KNOWLEDGE. Less acute patients which lets be honest, is 90% of the workload, well, my workload anyway, are HARD they take high levels of KNOWLEDGE and little skill.

"BLS has better patient outcomes than ALS" "You may think your a cool paramedic with all those fancy skills but remember OPALS..." I hear this and variations of this on multiple EMS forums a the time. The same people that say these things all the time like to also push the idea that BLS is solely in the domain of the EMT, and ALS is solely the domain of the paramedic. Somehow in their mind, the fact that limited scene time in severe trauma is better than stay and play equates that EMTs are the gold standard for patient care in the prehospital setting. These people also like to point out that ambu bag ventilation with a "BLS" airway may be better than intubation in some patients. True. However these same people seem to interpret that as EMTs are better for these patients than paramedics. Who is better at BVM ventilation: An EMT who bagged a mannequin a few times in class and MAYBE once during the ER observation, or, the paramedic who was an EMT and than spent time with an anesthesiologist in the OR learning the right way to hold a mask before they even touched the laryngoscope? It was in the OR that I learned that a BVM is not a BLS tool, but a medical device that required expert training to use properly. Can you get expert training in a EMT tech school that has no access to experts in airway management? It blows my mind that certain things are considered basic and advanced when they are not. They are just medical care.

You do make a good point Dust but I think its somewhat utopian to say that we can move to a single level system just like that (snaps fingers). Any system is going to have to adjust and even the best sysems in the world have more than one level, at the very least they have two; either Technician/Paramedic (UK) or Paramedic/Intensive Care or Advanced Care/Intensive Care. Nursing has public health nurses, coronary care, emergency, renal, operating theatre, mental health etc. Fire has firefighters, engineer/operators, station officers, captains, cheifs etc. There are really differnt levels of specalities within each profession just as there are to many types of professions; a pilot might fly a 737, a helicopter, a twin Cessna or an Airbus but he is still called a pilot. A "Paramedic" might be a Paramedic but she might specialise in (well, hopefully in my truck but failing that .....) neonatal care, community care, intensive care, critical care etc. They all have the word "Paramedic" in them. Get rid of this Technician crap and just call every ambo a Paramedic. I know this is a departure from some of my rant on other topics but I do really feel that it's a good thing. You might realistically have ... Intensive Care Paramedic (ALS) Critical Care Paramedic (CCT) Community Care Paramedic (ECP) Neontal Care Paramedic etc

No offence, as I know that you are just now starting out on this quest for knowledge, but I have to say your current plan sucks. Back-asswards, to be specific. Go to RN, RT, or whatever you are going to do FIRST, then go to medic school. Establish a career before you waste time or money on a hobby. Establish a foundation of EDUCATION before you piddle around with tech school TRAINING. Yeah, I know it doesn't sound as exciting, but then again EMS isn't the blazing ball of excitement you think it is from watching "TRAUMA" either. Do what makes sense for your family, not what sounds exciting. Good luck!

Ummmmmmm. I cannot even comment. I am less intellegent for reading this.

Wow... Just wow... Ok, I do agree with you about fire needing to get the hell out of EMS. But not about anything else. You're focusing all on skills, which I know is the basis of this thread, but not going into education. I'm a fan of making medic the entry level with a CC level that is a BS degree'd provider. An AAS medic might have the knowledge to start to understand what's going on with the basic patients, but if we want to grow as a profession we need to stop the emergency only mindset and actually concentrate on those 'bs calls'. We can do a whole lot more good if we became a real branch of medicine instead of the bastard step child of both medicine and public safety. If we started working community health as a full provider, we could help bring down the clog that ERs all over the country have. Look at Oz and NZ, those countries are closer to what we should be. But of course, none of this can happen without us getting our asses in gear and standardizing EMS throughout the country. None of this volly vs paid vs private bullshit. None of this glorified boy scout (basic) vs ALS level arguments. We need to pull our heads out of our asses and look at it as medicine. Oh, and BTW soem of the best medics I've worked with never spent a day in the field as a basic. They concentrated on their education and being the best at patient care. Not mastering a few skills you could teach a monkey to do.

Well, that says a lot about you and your contribution to this discussion. The only way is the American Way...... Arrogance AND stupidity, you'll go far..... WM

This is flawed logic. An EMT-P is an EMT-B. Most paramedic programs require you to be a basic for awhile before you become a medic. Basic skills.....are basic. That's why its a one semester class. How many times do you need to backboard and splint someone before you master it? Direct pressure and a trauma exam isn't rocket science. It's more common sense. I've seen way more clueless basics on calls then I have medics.

This. And if you can find a community college with concurrent enrollment, you can get HS and college credit for some of those classes like A&P 1 and 2. It will also give you a solid foundation for advancing out of the first aid (basic) stage and onto a real career like nursing

<br /><br /><br /> That's a good question. They certainly have been used to deal with the fluid shift, but on the erroneous assumption that there is an overload of fluid. The key term is 'fluid shift'. Eliminating the fluid in the system does not necessarily correct the fluid shift (it's not systemic overload we are usually worried about with ACPE - it's fluid in the wrong place, not too much fluid) and can lead to further problems with electrolytes (K+ in particular of course) and long term poor outcomes. Nitrates and ACEI's all serve to better correct the imbalance between hydrostatic and colloid oncotic forces that are the main problem to allow the fluid to shift back (or rather be taken up by the lymphatic system) and CPAP splints alveoli open to improve oxygenation and the problems that come from the V/Q mismatch (and shunt if really bad) (hopefully someone else can explain that better than me) Regarding long term CHF patients with an exacerbation, there are two schools of thought. One is that diuretics are appropriate as this may at least in part be a problem that has overload as a contributing factor. The other is that in the face of the sometimes quite substantial amounts of furosemide that these patients are taking alreadsy, a small amount may just be peeing into the wind and not achieving anything. To be honest, I am not sure how much data there is or isn't to support either of these positions. I currently am coming down in favor of giving the frusemide to these patients, but really, I'm not sure whether that is to make them feel better or me feel better... And it is only in cases of documented fluid overload that I consider it. I certainly would like to think that the potential to do harm with furosemide that we have in the true acute cases is not there for the acute on chronic cases. I stand to be corrected on this though, so if anyone else has a position, or better some data to support one way or another I would love to see it. That probably doesn't help a great deal though does it? I'll have a fossick around tomorrow and dig up some studies to support my ramblings. Paramagic

This is not an us vs them or ALS vs BLS thread. It is a thread discussing the needless use of such labels (als and bls) and the education needed to preform medical procedures that should (and every other profession does) require at least masters degree preparation.

Thanks, long time lurker, first time poster.... At this stage, generally speaking, I would be in favour of removing lasix from the drug box, at least for the setting of suspected pulmonary edema - nitrates, CPAP and ACE Inhibitors are first line treatment for this, and irrespective of the difficulties with differentiating ACPE from pneumonia, it probably leads to worse outcomes. However, while there seems to be less and less of a role for it in the setting of ACPE, that is not to say that it does not have uses elswhere in pre-hospital care (hyperkalemia for example) although these instances may be rare, and a cost/benefit analysis should probably be undertaken. I am, however, firmly against protocolisation (is that a word?) of emergency medicine as the sole form of clinical risk management. The first line of clinical risk management should always be education. In some cases further protocolisation may be required, but it shoud be a last resort. Something else we need to be careful of is being against losing 'skills' or drugs for reasons other than patient care (ie. ego). There often seems to be an attitude that removal of a particular drug or procedure somehow reflects badly on us as paramedics (not that I am trying to imply that this is your stance; this is just a general observation) Now, if this has occured because, say we have been unable to differentiate between the decapitated/non-decapitated patient, then fair enough, we should be ashamed. However if it has occured because the best available evidence demonstrated no benefit, or even harm from using it, then we should happily wave it goodbye and maybe give it a Viking Burial at sea. We need to practice emergency medicine, not massive egotism. The studies quoted earlier in the thread seem to me to relate to a systemic problem in the diagnosis and management of a particular cohort of patients in a particular service. One needs to be careful with making generalisations regarding our own practice or service from these kinds of studies without having read and understood the study in it's entirety, including any methodological errors before making decisions regarding it's applicability to our own specific circumstances. When we just read abstracts we end up with blanket statements being made like "RSI is bad, mmmmkay" that may not be appropriate depending on ones circumstances.

Wendy, Thankyou for reading my mind and posting it in an intellegent, well thought out, and brief post. To build on what you have already stated. I think it is important to point out that we should focus on providing "medical care". Whether it be holding your patients hand or making them smile. I think we to often forget, we are in this business to not just help people but to improve the quality of life. BTW, is hand holding a BLS or ALS skill? <------------ that is a trick question. It is just good people skills.

BLS before ALS? How about we just give our patients the medical care they require. Putting a patient on oxygen is not a BLS skill, its medical care that is preformed by CNAs all the way up to MDs. Also, what is the obsession with calling medical procedures "skills" instead of "procedures". No one else calls intubation a skill, it is a procedure. Are we in 1st grade again going to motor skills class? And as mentioned by multiple posters above, doing procedures requires education not training.

Welcome my friend, welcome to the other side. Now, I know I'm going to be preaching to some of the converted here but still: If it is one thing that annoys me the most about EMS it's this American attitude of "BLS vs ALS" and its like you blokes think they are somehow an actual procedure to be carried out like splinting a broken arm "oh I gave this patient BLS" mmmm yes .... Because this patient is stable he is a "BLS" patient even tho he's been shanked in the stomach but only has a teeny-weeny hole despite the fact he is gonna crash ten minutes into his "BLS" transport. All patients to not require "life support" and I think this is an outdated term, as you said they require care. Most care is very simple and carried out by all levels of Ambulance Officer be they a "BLS" level Technician or an ALS level "Intensive Care" officer. Included are the essential primary elements of practice like communication, safety, history taking, vital signs, physical assessment etc and does not vary between practice levels except maybe for 12 lead ECG monitoring, you can also include fundamental patient care like splinting and transporting, oxygen, salbutamol etc. This is one of the reasons I am really pleased with the way Ontario has structured its education program for Pirmary Care Paramedic; it's two years and includes the in-depth education in A&P, patho etc so that they can go in and conduct a good, detailed assessment and differential diagnosis of a patient and begin to hone and develop thier skills and knowledge rather than just a two page four hour class on how to take a few vitals and ask SAMPLE questions, for example. Australia with it's Advanced Care Paramedic (ILS) internship and post-graduate qualification for Intensive Care Paramedic (ALS) also offers a good comparison to draw here as they should offer simmilar outcomes. Ask your basic EMT to tell you how to differentiate between say indigestion and .... a gallbaldder attack for example. Some care that ambo's offer patients is quite invasive and advanced; such as rapid sequence intubation, thrombolysis and chest decompression. These advanced skills require a solid grounding in bioscience and extensive experience, competency and overall a high level of confidence which is inherently linked back to the other competencies I outlined. It takes four to five years to become an Advanced Care (Canada) or Intensive Care Paramedic (Australia/NZ). Contrast this with some dude who has 700 hours of education over 14 weeks at the Houston Fire Department's Paramedic-R-Us patch factory. You mentioned fundamental skills like bag mask and this is often a problem I see with people. They bag the snot out of patients and don't understand the reasons why they shouldn't. Try to explain to them about hyperoxemia, hypocapenia or dynamic hyperinflation and they just give you a glazed over look. Ask any ambo how GTN works and they'll tell you "dialates blood vessels" and no more. So who does which? Which what? Well if we want to refer to "life support" my argument is that ambo's don't really do that and I am sure a lot of intensivits and ICU RNs will agree with me. My spin is that "care" is provided. Therefore we should do away with this "life support" nonsense and embrace what Canada has done; term everybody some level of "Care" (ehem, Alberta and Manitoba excluded, whacky Albertobaians...) because that's what 99% of my jobs have been .... providing CARE and not "life support". Two level systems (US) Primary Care (old BLS) Intensive Care (old ALS) Three level systems (US) Primary Care (old BLS) Advanced Care (old ILS) Intensive Care (old ALS) Everywhere else in the world smart enough to not have a "BLS" level Advanced Care (old entry to practice) Intensive Care (old ALS) Until you guys fix that whole BLS vs ALS crap it'll continue to be what makes your system a joke.

Personally, I think that's just sloppy and perhaps laziness on the part of the EMT's dressing themselves like that. It's not a fashion show, however some care has to be taken in our appearance as we are after all in the public eye. We should look professional. As for services that require employees to buy their own uniforms ... I wish there was a way around this. I've worked for places that dictated this and it got expensive, especially when the wages weren't all that great. Fortunately, basic uniforms/jackets/boots/safety gear are provided to me now. As for anything extra such as insulating winter clothing etc etc, we are responsible for that ourselves. There is however a way to tax deduct that stuff ...

Don't tell them that. Decide ahead of time whether you need to work full or part time to fit in everything you want to do, and then go to your interview and tell them that you will do that job (be it either full or part time) to the best of your ability.

+1. Some sound like broken records on these EMS forums. Like I've said elsewhere, the only plausible way to change anything would be to earn either an EMS BA or BSN, take over EMS admin positions, and change things from up top. Expressing resentment and frustration towards the fire service is corny and changes nothing. Too bad that fire based EMS systems can work well if run properly. I know that it's easier to convince oneself that being dual role makes you less effective at either discipline, but I've seen plenty of evidence to the contrary. Yes, I can do your job just as good as you and do equally well with suppression duties. The trend is more toward dual role fire based EMS rather than single role muni/private. This is true even in these tough economic times, where systematic changes won't happen without cost savings or increased efficiency. As we speak, Alexandria Fire and EMS is planning to change all their dingle role medics to dual role. That's maybe 100 or so firemedic jobs vs the four that were lost in the Canadian city on the other thread here. Instead of taking pot shots at the fire service (sticks and stones....), get a four year degree, go admin, cease hiring basics, and require all medics to hold degrees. When enough medics hold degrees, the medic mills will be run out of business. Then, either EMS only organizations (which will finally hold power since the entry would be degreed medics, and therefore a less transient workforce) will reclaim fire based EMS territories, or firemedics will all be degreed, and therefore strong providers.

Yep, had partners of ALL levels freeze, including pre hospital doctors, on calls and some even needed a slight gentle nudge across the back of the head to get them moving. That is not a ALS/BLS issue that is a person to person issue. What I am saying is that the ambulance crew should be just that - a crew - not two individuals working the same truck. Maybe it is just me expecting too much from my partner and maybe it is a good reason to ahve two paramedics on each truck???

Well at least I learned a new abbreviation Thinking of putting my own spin on it .... S squared D squared I dunno cheers

Let me put it this way. There are dozens if not hundreds of very impressionable young medics out there who read our words and take our words of experienced knowledge to heart, as erroneous as some of it is. Something like this is not as clear cut as it seems, and the last thing I want to find out in the news is that a maternity patient had a bradycardic episode that became asystole, and rather than treating the mother, these impressionable rookies recalled our conversation and grabbed the scalpel instead of the atropine because they heard somewhere that some medics think it is best for the mother to be dissected to save the baby. Now, to your question, do I feel competent to do it? Yes. Would I do it? Perhaps under the following conditions. I know exactly when the mother went into cardiac arrest, I know I have the approval of the next of kin in writing, I know that the mother has sustained injuries that will prevent her resuscitation of any sort, I know that the mother is unable to be transported immediately with CPR enroute, I know that my transport time will be a death sentence for this fetus I know that the fetus is still viable I know that my medical control is on board, and I know that I am comfortable with the possibility that after this call I will never be permitted to perform even a blood pressure on a person ever again and that I will likely be spending the next 20 years in court defending my actions, and likely penniless because my malpractice insurance will not cover me for working outside my scope of practice, regardless if the child lived or died. BTW, the 20 years? Not an exaggeration. The child will also have the right to sue me once he turns 18. There is the reality of it, If all those conditions were met, I would be happy in knowing that this child was actually around to sue me, even if he is trying to ruin my life for saving his. The fact that the mother is dead is irrelevant to the situation. If we had nothing in our arsenal and training to reverse this condition, then it might. The fact that we can actually reverse death means that the adage "She's dead, so it doesn't matter what you do it can't get any worse." is not applicable. First, we have to ensure that we tried to fix a fixable condition, otherwise why bother taking ACLS training? It's not over for our patient when our patient is dead, regardless how pregnant she may be otherwise we might as well just start using every code patient we treat for cadaver training instead. Even a patient with a head crushed to 3 inches thick may have enough lower brainstem function to be able to maintain adequate perfusion to the fetus until such time as it can properly be extracted.

Somehow I doubt the instructors are thinking the student will be slicing a pregnant woman from xyphoid to pubis though. There is a big difference between trying to save a life and making an error compared to trying to save a life while at the same time causing a mortal injury that will completely prevent the possibility, faint as it might be, of resuscitation. Sure, if they fit within the criteria of my protocol for pronouncing death in the field, my position may change, but if there is a potential for ROSC, I'm all over it. I also suspect that one without the training or skills will survive a legal fight in this day and age. 25 years ago was a different era. Fortunately for that baby, the medic didn't put his brain into gear before grabbing the scalpel.

Hey David, I know some high schools actually run an EMT course as a class. You might want to check with your school to see if that is available and you just weren't aware of it! Other than that, I suggest joining a local volunteer fire/EMS department if available. It's a perfect way to gain experience. Try checking local hospitals as well, if you'd like to try to get into an EMT class in the future. I know my local hospital runs an EMT-B course yearly! Best of luck to you

There is no "head start" through experience. The only head start that will benefit you is through education. Take Biology, Anatomy & Physiology if available. Take chemistry. Take an expository writing course. Take advanced math. Take psychology and sociology. Take physics. Take weight training. Believe it or not, high school is capable of providing an excellent foundation for EMS practice if you aren't too blind to see the possibilities. And those courses will go LIGHT YEARS farther to prepare you for EMS practice than any piddling around with a volunteer department or Explorer post. In fact, both of those are well known to retard your progress as a new medic.

Hey chbare! Pretty cool you're taking the time do do a scenario! 8 year old brother, regardless of first language almost certainly speaks english..can/will he shed any light on this? List of meds parents may be taking. Any obvious OTC/home toxin (under the sink)/alcohol containers? Other than upset, other family members acting normally? Dwayne

Haha perhaps we should start a new topic about it?

Did you try Google? Here are a couple of links I found there. http://www.ottawa.ca/residents/health/support/professionals/cbnre/lacrimators/teargaspepperspray_en.html http://www.thepersonalsafetyguru.com/safety/550-treatment-for-pepper-spray-exposure/ And here's the other 338.998sites listed on your topic. Hope this helps!!

How about I don't care about your silly non-american systems. In a big urban fire systems your emt's are firefighters and have very little but a fast ride to offer as patient care/skills. Paramedics are king here and minus burnout and laziness if you want advanced care you hope you get them. Get over the terms they are not going to change.

Thanks Tskstorm Wow, each post from you gets dumber and dumber. First, I am not your "Homeboy" Grow up, what are you, a 15 year old Gansta wannabe? Perhaps you should research your comments before posting, or would that require shifting your brain out of neutral. Age discrimination law in: The United Kingdom: http://www.equalityhumanrights.com/en/your.../Pages/Age.aspx Australia http://www.hreoc.gov.au/age/index.html Canada http://www.ag.gov.bc.ca/human-rights-prote...crimination.pdf United States http://assets.aarp.org/www.aarp.org_/build.../adea_paper.pdf Although some countries allow age discrimination in certain circumstances, this case is definitely not one of them. You don't even know what caused her death. Perhaps it was a genetic heart defect heretofore undiagnosed and she could have dropped dead at any time, even when she was 25. Age does not cause people to die. Her age had no relevance to her death. The CPAT has nothing to do with age. Do you even know what that stands for? It's not Can't Permit Aged Toiling? If an individual is 60 years old and passes a CPAT, does he not get the job because he's too old for your tastes?

So here we go again us verse dem. I have to wonder why after countless blogs, posts and forums it is apparent to me that the bls vs als is unwinable. ALS will always FEEL SUPERIOR, and lets be truthful they are more educated. If all of us slimmy, no good,communist, uneducated bad spellars and chicken thievin basics were to advance up to als they would be left with little to complain about and no one to ridicule. So in reference to that 'your welcome' I would hate to leave all the ALS providers melancholy. They might turn on them selves and begin to eat there young.

BLS before ALS you have to be an emt for a year atleast before you can start to be a medic.good emt skills is what makes a good medic.i dont give a damn if you are ALS is you cant to the basics then you are no good to me.think about how many ALS calls really go down on any given day,where i work(in manahttan) alot of calls get upgraded by the callers because they want an ambulance to get there faster but when you get there its bullshit. yes ALS is hard,i was in medic school til i got hurt at work and had to drop out but so is emt work.medics need us and we need the medics.alot of places double as bls/als and are usually run by fire and thats the true issue imo. if you are a fire fighter then thats great but the system should be kept seperate.ems should be run by someone who has medical traning and not by a fire fighter. getting back to which is better,neither is better,its what you know and how you do it.i can start a line,do the leads and push drugs better than some of these medics out here but i have seen als do better immoblization and basic bleeding control better than some of the techs who have been on the job for 20 years. if you are an medic then you need to keep up your emt skills because all als protocols say BLS interventions first and just because we are on scene there to help you otu doesnt mean have us do all of that because you dont want to.learn the new tricks from your emts as for the techs learn the simple things from the medics like how to spike a bag or how to put the leads on the pt. ems isnt going to go anywhere if we keep bashing eachother,als saves bls but its bls skills that saves als