Dr. Bledsoe says EMS at a crossroads

[JakeEMTP]

Once again I have to agree with Dr. Brian.

I was doing some research for a class and this one pop up.

http://www.ems1.com/research-reviews/artic...dence-based-EMS

I have often wondered if what we do makes a difference. I agree that in serious trauma a "diesel bolus" is the best we can offer. Cardiac arrests' are what they are. Sometimes it goes well, but most of the time despite our best efforts, the outcome isn't a positive one.

I believe I do make a difference for the majority of the patients' I come in contact with and will continue to think that way.

[paramedicmike]

I believe I do make a difference for the majority of the patients' I come in contact with and will continue to think that way.

Is this because you "have seen it work" or "your department does it differently"?

There are very few patients for whom I think my actions have made a difference. I agree with you. Doctor Bledsoe is right on with his assessments. But this is why I question your last statement. It seems to directly contradict the argument he is making.

-be safe

[JakeEMTP]

Is this because you "have seen it work" or "your department does it differently"?

There are very few patients for whom I think my actions have made a difference. I agree with you. Doctor Bledsoe is right on with his assessments. But this is why I question your last statement. It seems to directly contradict the argument he is making.

-be safe

Mike,

I understand what you are saying. I guess what I meant was that I do see that I do make a difference. Hypoglycemic patients I can help. CHF pt.'s I can help. Respiratory emergencies I can help. Anaphylaxis I can help. While we can make a difference in the majority of our patients, the minority is what bothers me the most. I realise that we are not the be all and end all. That we are there to transport the patient to definitive care, but it is the short time we do see the pt.'s that we can make a difference.

We all know the effects of the administration of D50 has on the hypoglycemic pt. Without it, most would indeed die. CPAP in the field. I have had a pt. who was making snoring respirations UOA, actually carry the O2 bag to the ambulance. The list of interventions we can do to render aid is minimal in the grand scheme of things. It's what we DO do with them that makes the difference.

Maybe it's my newness to the field, but I feel we as paramedics can and do make a difference.

[Lone Star]

*DISCLAIMER* I am NOT trying to 'flame' anyone or license level here. I am merely making an observation based on the article that Dr. Bledsoe wrote.

He references a quote taken from Dr. Greg Henry:

There is no data, not one study, which shows that anything beyond the intermediate level — basic EMT with defibrillator capabilities — does anything in the long run to change the health care of the United States.

Since I've seen so many here in the forums quote Dr. Bledsoe so reverently, this tells me that he is regarded as a leading voice in EMS.

That being said, since Dr. Bledsoe has found this particular quote of Dr. Henry important enough to reference in his article, I'm led to the following conclusion:

Since there is no data to support the claims made by the paragods on this forum, it would appear that rather than eliminating BLS from the EMS field, it looks as though the 'Basic bashing crowd' can no longer 'justify' their existance.

I am in no way calling for the elimination of the ALS crowd; I can only hope that the paragods that go around bashing the lower license levels as 'insignificant' because they're not ALS; are served this 'wake up call', and step down from their soap boxes and 'high horses' and quit bashing the other levels of EMS.

If the EMS structure needs to be 'revamped' so that we can evolve as a profession, then so be it! I am not against higher educational levels, nor am I against stricter educational standards. I AM however, against all this grade school BS of 'My books are heavier than yours, so therefore I MUST be smarter than you, and I'm more important too!"

There has been many pleas for the senseless juvenile bickering to stop, and I think that if this article serves any purpose, it's to finally put an end to the paragod syndrome that seems to afflict so many Paramedics!

[akroeze]

*DISCLAIMER* I am NOT trying to 'flame' anyone

it's to finally put an end to the paragod syndrome that seems to afflict so many Paramedics!

Unfortunately the evidence seems to contradict your opening statement.

[VentMedic]

I am in no way calling for the elimination of the ALS crowd; I can only hope that the paragods that go around bashing the lower license levels as 'insignificant' because they're not ALS; are served this 'wake up call', and step down from their soap boxes and 'high horses' and quit bashing the other levels of EMS.

I see a greater need for advanced EMS education from this article. It actually takes more education to understand why you are not doing something rather than "you are not doing it because you can't" if it is not within your level of training.

I also see it as a call for more education to better understand why things work and why not instead of "it's in the protocol". It's time to understand the difference between guidelines and recipes. That might mean taking classes such as college level pharmacology and A&P. Too many people are blindly led by articles in JEMS, or some other non-scientific magazine, without being able to differentiate fluff from science.

It also means we can not justify 4 Paramedics on an ALS engine or ladder truck if there is another ALS transport capable truck running with it.

[fireflymedic]

Here is my thoughts on the topic for what they are worth.

Most of the research is done in urban areas where hospitals are no more than 15-20 min away at most in traffic. Most places have multiple hospitals within easy reach of them. If they were to conduct their research in rural areas, the opinions might be quite different where the transport times are much longer (mind you along with response times) so patients are in much different positions than say in the city. Having worked both urban and rural EMS I can say there is a definite difference. I can see how in a urban setting within minutes of a hospital ALS capabilities and benefits are limited. However, I disagree strongly with this theory within the areas I serve. It's definitely a different ballgame. You don't believe me, come ride with me for a day. I disagree with the comment that the treatment I have provided has not made a difference. Many times, my ability to respond and treat on scene and release has allowed people who could not afford an ER visit or transport to receive what they needed. Perhaps in other areas it's different, but I do see the difference my services make every day.

That being said, good BLS skills are essential to any caregiver and I will NOT waiver on that decision. Anything from a first responder to a CCT medic need to have excellent bls skills, the most important of those being truly good assessment skills (the biggest thing I see lacking in new hires at surrounding departments). As I've said many times, your box of toys fails, you have to still manage the patient BLS and those skills better be excellent to give that patient a fighting chance. Basic or medic it doesn't matter, you have to assess, treat, and manage your patient to the best of your ability. No need to fuss about who's better and who's not.

And just a side note, while I respect Dr. Bledsoe and believe he does have EMS best interest at heart (or at least seems to) he needs to investigate some into EMS beyond urban settings before making comments. I must respectfully disagree with him on this issue.

[Lone Star]

Unfortunately the evidence seems to contradict your opening statement.

Had I been intent on 'flaming' anyone, instead of simply naming the 'syndrome' that seems to affect one license level more than others; I would have started naming names. Since I didn't, it would seem that I have stayed well within the self imposed confines of my original opening statement, thereby making the disclaimer a true statement!

[defib_wizard]

While I respect the opinions of Dr. Bledsoe in this case I will have to disagree with him on some of its points. I remember a comment by another Dr. years ago that stated the public is just as well off to get a ride to the hospital in a cab than in an ambulance. That comment was ignorant and so are some of the comments in the article. Evidence based medicine is a good thing but it is difficult to get this evidence. You have to consider how the evidence is gathered, along with the results long term and short term. Remember when we gave bicarb to all codes then thought we must be doing good, look at the pts blood gasses. Nevermind that inside the cells we just increased the acidosis.

Lone Star wrote:

I am in no way calling for the elimination of the ALS crowd; I can only hope that the paragods that go around bashing the lower license levels as 'insignificant' because they're not ALS; are served this 'wake up call', and step down from their soap boxes and 'high horses' and quit bashing the other levels of EMS.

Emts with defibrillators can and do save lives. The majority of our calls can be " handled " with a bls provider. Its the ALS patients that need a paramedic and there is no way of knowing what type of patient it is without an assessment. What can you do besides drive really fast with a patient in complete heart block and a pulse of 20! I can treat it and go to the hospital in a safe manner. The unstable patient in SVT at 220 needs cardioverted, an AED isn't going to work because the patient is still alive. So I disagree with an EMT I with defibrillator impacts patient outcomes as well as a paramedic.

Intubation on trauma patients; if you are unable to protect your airway due to trauma your prognosis is already poor. Does intubation increase your mortality. That would depend on multiple factors. Medicine is a risk verses benefit art treated like a science.

How do you do this study? Every trauma patient is different, do you not intubate certain pts. How do you obtain consent to be included in the study if the pt has a GCS of 8 or less.

If your patients becomes hypoxic due to multiple ETI attempts the you are doing more harm. The system I work in gives you 3 tries then an alternate airway management is to be used.

The trauma patient needs 2 things - blood and surgery & they are at the hospital. but if the patient has no airway then the patient is dead. Aspiration is also deadly. By me being able to secure a patients airway that patient can go into surgery much faster. But if my ET tube helps prevent aspiration then that can improve the patients outcome. I am not talking about RSI.

In my area the closest trauma center is approx. 60 miles away air transport to that facility can and does make a difference in patient outcomes. The community hospital has a 5 bed ER an 1 DR. with 1-2 nurses to staff it. We fly a lot of patients to higher care.

Ok I hit it back across the net. I'll get ready for the incoming comments.

[VentMedic]

Emts with defibrillators can and do save lives. The majority of our calls can be " handled " with a bls provider. Its the ALS patients that need a paramedic and there is no way of knowing what type of patient it is without an assessment. What can you do besides drive really fast with a patient in complete heart block and a pulse of 20! I can treat it and go to the hospital in a safe manner. The unstable patient in SVT at 220 needs cardioverted, an AED isn't going to work because the patient is still alive. So I disagree with an EMT I with defibrillator impacts patient outcomes as well as a paramedic.

Intubation on trauma patients; if you are unable to protect your airway due to trauma your prognosis is already poor. Does intubation increase your mortality. That would depend on multiple factors. Medicine is a risk verses benefit art treated like a science.

How do you do this study? Every trauma patient is different, do you not intubate certain pts. How do you obtain consent to be included in the study if the pt has a GCS of 8 or less.

If your patients becomes hypoxic due to multiple ETI attempts the you are doing more harm. The system I work in gives you 3 tries then an alternate airway management is to be used.

The trauma patient needs 2 things - blood and surgery & they are at the hospital. but if the patient has no airway then the patient is dead. Aspiration is also deadly. By me being able to secure a patients airway that patient can go into surgery much faster. But if my ET tube helps prevent aspiration then that can improve the patients outcome. I am not talking about RSI.

In my area the closest trauma center is approx. 60 miles away air transport to that facility can and does make a difference in patient outcomes. The community hospital has a 5 bed ER an 1 DR. with 1-2 nurses to staff it. We fly a lot of patients to higher care.

Ok I hit it back across the net. I'll get ready for the incoming comments.

Dr. Bledsoe is not calling for an end to ALS protocols but to make us think why and where is the evidence for many of our procedures in the field. Again, too many do things because they can and not because they should. I already stated my position on education in an earlier post.

As far as intubation of trauma, I sometimes prefer intubation in the ED or OR because of the ETTs that are used do prevent aspiration and VAP. They have subglottic suction ports. A regular ETT does not prevent aspiration but rather slows the inevitable. To prevent VAP, the removal of secretions that are trapped beteen the glottis and cuff must be continuous. Review: anything that gets past the glottis is aspirated.

Often we will reintubate a patient either in the ED or OR for that purpose. This, of course, makes some Paramedics cry foul because they don't understand why we are doing it. Facial trauma patients will also get intubated with another type of ETT that allows manipulation or immediately trached which can be done quickly and under ideal circumstances...in trauma centers.

However, ALS providers are secure in their future and this can lead to enhanced arguments for more education including increasing the EMT-Bs' hours.

As far as consent, many of the procedures that are being trialed in EMS have already been proven in the hospital situation so it is not like you will be doing a new drug with unknown side effects. However, what is not followed very well is how well those procedures work in prehospital. Ex. RSI, CPAP, thrombolytics, pain management, hypothermia protocol, etc.

Good Research article:

http://www.pcrf.mednet.ucla.edu/pcrf/pdf4.pdf

EMS education curricula do not include adequate research-related objectives. Thus, very few EMS

personnel, including system administrators and managers, have a sufficient baseline understanding and

appreciation of the critical role of EMS research. Unlike most other clinical fields, EMS research often is

conducted without significant participation by its own practitioners, relying instead on others.

And one more research article:

http://www.nedarc.org/nedarc/media/pdf/Res...MS_Research.pdf

Lastly:

National EMS Research Agenda

http://www.researchagenda.org/