The Argument for ALS Level Care

[akroeze]

Hi all,

The municipality I live in is in the process of reviewing their EMS service. Specifically we are currently having EMS provided by a contracted private company that provides care at the Primary Care Paramedic level. I plan on writing a letter to my city counsel making the strong argument for the implementation of an Advanced Care Paramedic program here and would appreciate the help and expertise of you folks here.

I will quote some info about the place:

"At 2,458 square kilometres, Chatham-Kent is the twelfth-largest municipality by area in Canada and the largest in southwestern Ontario. Over 59,000 of the 110,000 residents live in the former City of Chatham."

In the main community of Chatham they have 2 trucks 24hrs/day in 12hr shifts with an additional truck 0800 to 0000 in 8hr shifts (1000-1800 coverage only on Sundays). The surrounding communities all have one each of which there are 4 with 24hr/day coverage in 12hr shifts. Finally there is a first response truck staffed by a medic 24hr/day 12hr shifts in one other community.

So in summary:

-6x24hr trucks

-1x16hr cover 6 days per week with 8hr on Sunday

-1x24hr first response truck

There are two destination hospitals, one in the extreme north end of the municipality with the other being in the geographic centre. The furthest point from a hospital is basically 50kms with the majority of it being 80km/hr roads.

The Primary Care Paramedics:

-2 year college diploma

-Semi-automatic defib

-3-lead monitoring (not 12-lead)

-ASA

-Nitro (Chest pain, Cardiogenic Pulmonary Edema)

-Salbutamol (MDI and nebulised)

-Epi (Anaphylaxis, Status Asthma)

-Glucagon

-Gravol (anti-emetic for IM admin only)

-Glucose gel

-King LT airway in arrests only

Some (not many at all) are additionally certified in:

-IV initiation with protocol for fluid bolus if needed

-Dextrose IV

-Gravol IV

So with this in mind, what are some examples I can use in this letter? Things that come to immediate mind are seizures and pain control.

I'll post a link to the draft of the letter when I have it written so I can get your input. I would really appreciate your help.

[fiznat]

Sorry just to help us US folk understand, what can the "advanced" paramedics do that the current level cannot?

From what you've typed so far, looks like early 12 lead with cath lab activation by EMS might be one of your major selling points. This (the activation part) was just introduced in our system and we are already seeing major changes in door to balloon times. I feel it is one of the most substantial things we do out in the field to reduce morbidity and mortality. Opiate pain control might be another big deal, especially considering how pain control is getting more attention these days in the medical field. This is another area that I think EMS can have a real impact on their patients, and something your current system seems to be lacking.

[rock_shoes]

Push hard Akroeze. Even BC Ambulance (one of the countries stingiest services with ACP's) provides Advanced Care Paramedics for communities of a similar size to the one you describe. Don't expect to be able to have all the cars converted but at least 2 of the 24 hour cars should be. Given the educational standard for PCP's in Ontario de-pairing might provide the opportunity for 4 24 hour ALS cars.

[rock_shoes]

Sorry just to help us US folk understand, what can the "advanced" paramedics do that the current level cannot?

From what you've typed so far, looks like early 12 lead with cath lab activation by EMS might be one of your major selling points.

Advanced Care Paramedics (ACP's) run and interpret 12 leads, multiple cardiac med's, perform ET intubation, all have IV access, pain control med's, etc.. The scope is similar to that of a US EMT-P with a relatively progressive medical director. In some provinces like Ontario there is another level beyond ACP called Critical Care which has a similar scope of practise to a CCRN with some parts of a good respiratory therapy program thrown in. All this might seem a little strange to our southern neighbours. In Canada PCP (which is a similar scope of practise to EMT-I) is considered to be a BLS level of care.

[crotchitymedic1986]

The best thing you can do is to show real life examples. Go through your 2008 calls and see if you can show real life examples of how your suggestion would have improved care. In any proposal, a cost benefit analysis is a mandatory requirement, you can google that if you do not know how to do one. Most political types are only concerned with the increased cost, so you have to provide an arguement (or benefit) as to why it is a good decision:

Example: Hospital employee wants to do free glucose screening exams at the local Walmart. It will cost the hospital:

Payroll: $30.00 hour for 6 hours = 180.00 + 15% for benefits/taxes = $ 207.00

Fuel Cost: $ 5.00

Supplies: Will stop at 200 patients or 6 hours, whichever comes first = Cost of supplies for 200 tests = $220.00

Total cost $432.00

Their table with sign and logo will be seen by approximately 3,000 people that day, to get the same reach with newspaper advertising they would have to spend $600.00, so they may decide to do it, or not.

That is the kind of arguement you have to make.

[BEorP]

I wouldn't play the 12 lead card since there is no reason that PCPs can't do 12 leads and STEMI bypass.

[fiznat]

^^ Except the OP specifically said that they dont. If the "just add that skill to the current level" argument works, then why not use it for everything else, as well? Proper 12 lead interpretation requires a certain amount of skill and practice, not to mention a strong foundation in the physiology behind it. There is a reason lower level providers don't do it.

[BEorP]

^^ Except the OP specifically said that they dont. If the "just add that skill to the current level" argument works, then why not use it for everything else, as well? Proper 12 lead interpretation requires a certain amount of skill and practice, not to mention a strong foundation in the physiology behind it. There is a reason lower level providers don't do it.

Primary Care Paramedics can and do do 12 leads in Ontario.

[akroeze]

Primary Care Paramedics can and do do 12 leads in Ontario.

What he said, 12 leads are within the scope just this service doesn't have them. It definitely isn't going to be a focus at all as I firmly believe that all PCPs should have access to 12-lead as well. That and there is no cath lab in the area therefore no STEMI bypass would be implemented regardless of EMS 12-lead capability.

So i think I will focus on a few key cases in order of most attention given in letter to least:

-Pain Control

-Seizure Control

-Dysrhythmia Control

[BEorP]

It is all going to come down to money though. It may also be worth looking at the actual added cost, which wouldn't be that much if the service does not pay for anyone's ACP training.