BLS vs ALS

[tniuqs]

'armymedic571 Besides, I like the sun....

I perhaps am delinquent in my ALS survey ... any left over sand/dust in your shorts as chafing can be very irritating.

JakeEMTP

Just having a Physician on an ambulance does not mean the pt. would have a different outcome.

A very good point ... look to the French experiance with Princess Diana ... an MD on board may have been a complication in a delay of transport, although who would actually know ?

cheers

<edit must have screwed up on quotes again>

Edited February 13, 2010 by tniuqs

[armymedic571]

I perhaps an delinquent in my ALS survey ... any left over sand/dust in your shorts chafing can be very irritating.

A very good point ... look to the French experiance with Princess Diana ... an MD on board may have been a complication in a delay of transport, although who would actually know ?

cheers

Now that's hilarious . Are you saying that I am irritating?

The original post I saw was all rearranged. Genius.

Jeff

Edited February 13, 2010 by armymedic571

[JackMaga]

Don't be ridiculous. I would expect more from you.

My fault... it was intended as a funny remark, no offense intended! I'm sorry if you felt it was disrespectfull!

I don't doubt that many paramedics have the knowledge and education necessary to fully and completely evaluate and treat their critical patients: my post wasn't intended as a paramedic bash...

We're talking about education, and specifically about whether such thing as BLS and ALS care exists: most of the posters here expressed the view that patient intervention should be seen as a continuum, non categorized as advanced or basic. I completely agree. However it makes my self think: if field iterventions are considered as a continuum, why field care in itself is considered to be separate from hospital care so much that a dedicated provider has to exists? Why those that traditionally provide general medical care to the community (that is physicians and nurses) don't do it in the field too? Why do you feel this is appropriate?

Please consider this as an honest question, as in my part of the world all medical interventions are performed by nurses and MD, wheter it is in a operation room, a GP office or in the back of an ambulance or an helo...

And tniuqs, I never implied that you don't need the tools... I just said that the discussion was about education, not about skills...

Just having a Physician on an ambulance does not mean the pt. would have a different outcome.

A very good point ... look to the French experiance with Princess Diana ... an MD on board may have been a complication in a delay of transport, although who would actually know ?

I agree sometimes there may not be any difference, sometimes however it might... in my system for example I can refer my patient to their GP, I can treat them on scene. I'm not restricted to any protocol, I can have my own drug choice to carry on the ambulance; when I bring a patient to the ER I can continue my care until I have done all diagnostic and stabilization required and he is ready to be admitted to the hospital, so that he actually had one single physician who took care of him from the field up untill he is admitted to the ward...

As the implication that a physician would lenghten the time on scene, being an emergency physician means also that you have to know when you can stay and play and when you have to get going... after all I'm not some internal medicine doc who won't start treatment untilhe has done recording the pt. full family history!

Edited February 13, 2010 by JackMaga

[1EMT-P]

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.

While I support increasing the educational standards for EMS providers in the USA, I have to take issue with calling our system a joke. As I am sure you are aware just because a system is different does not mean that the care provided is not good. The USA has some very good EMS agencies including Medic One & Richmond Ambulance Authority just to name a few. There are pros & cons with each of the international systems that you mentioned. In other words my friend " people who live in glass houses shouldn't throw stones".

[tniuqs]

'JackMaga'

I don't doubt that many paramedics have the knowledge and education necessary to fully and completely evaluate and treat their critical patients: my post wasn't intended as a paramedic bash... We're talking about education, and specifically about whether such thing as BLS and ALS care exists: most of the posters here expressed the view that patient intervention should be seen as a continuum, non categorized as advanced or basic. I completely agree.

Can bet your boots on that one "many paramedics have the knowledge and education necessary to fully and completely evaluate and treat their critical patients" on the flip side what education do Family Practice MDs have in prehospital care, or crtical care for that matter, say extraction, rescue +++ and from some personal experience many "happened by MDs" can cause far more problem's than benefit. One then has to ask themselves who exactly is better educated in those areas ? Does it take 14 years to pop in a few superficial sutures or give broad spectrum antibiotics ps C+S is typically again, post mortum in many cases.

Unfortunately the scope of practice and protocol development (btw dictated in most cases are from MD's some ER some GPs) It can be considered not to be realistic and quite dependant on the latitude of the MD Only ... there rarly exsits clear boundaries from one service to the next.

However it makes my self think: if field iterventions are considered as a continuum, why field care in itself is considered to be separate from hospital care so much that a dedicated provider has to exists?

Just like a any specialist and in whatever area, does one need urologist to actually dx a kidney infection ?

Why those that traditionally provide general medical care to the community (that is physicians and nurses) don't do it in the field too? Why do you feel this is appropriate?

Ah you hit it bang on the nail ... traditionally .. treatment in many cases becomes turf wars, not what is cost effective care of delivery, look to the UK for some perspective globally, then OZ then SA, or better yet offshore Oil Platform.

Please consider this as an honest question, as in my part of the world all medical interventions are performed by nurses and MD, wheter it is in a operation room, a GP office or in the back of an ambulance or an helo...

Please consider this an honest answer: Pitty perhaps your country needs to reevaluate that there can be things to be learned from many other systems, I can think of quite a few countries that do not conform to this traditionalist perspective.

And tniuqs, I never implied that you don't need the tools... I just said that the discussion was about education, not about skills..

.

Goes Hand in Hand, can't have one without the other really ... but if one doesn't have the "tools" but has the education (frequently dictated again by overseeing MDs some overbearing too to be honest) and this can be very frustrating.

cheers

While I support increasing the educational standards for EMS providers in the USA, I have to take issue with calling our system a joke.

As I am sure you are aware just because a system is different does not mean that the care provided is not good. The USA has some very good EMS agencies including Medic One & Richmond Ambulance Authority just to name a few. There are pros & cons with each of the international systems that you mentioned. In other words my friend " people who live in glass houses shouldn't throw stones".

Edited February 13, 2010 by tniuqs

[Kiwiology]

Unless a physician brings the emergency department, a radiologist with an x-ray/CT machine and a diagnostic lab tech with him on the ambo he is no more use than a properly qualified Intensive Care officer.

Europe, parts of South America and Isreal use doctor (nr RN) based ambulances; SMUR/SAMU in France as an example. Germany uses prehospital physicians (as does Quebec in Canada) because the legislative arrangements do not permit Paramedics to perform restricted interventions; look at the Canadian definition of a "Paramedic" it is any ambulance attendant who can perform one or more controlled medical acts.

I don't think physician or RN based ambulances are required nor I venture a guess do they provide better ouctomes for thier patients; anedcotally they may because a physician or an RN might be able to use thier extra knowledge and training to perform a better assessment but I don't have any evidence for this.

As for who should lead the paramedic profession; well, paramedics; not firefighters or anybody else and that includes doctors. Ambo's should draw upon the resources that are out there in thier subject matter expert colleagues such as cardiologists or paediatricins but they should not be "led" or "overseen" by a physician.

Legislative arrangements, education, a definition of praxis and both an industrial and clinical leadership body is what is required.

I would propose the definition of a "Paramedic" be a health professional who provides emergent community based health assessment, treatment, referral or transport as required to ensure patients recieve the right health services for thier individual circumstance. This includes a variety of tasks including responding to life threatning emergencies, unscheduled care requests and health promotion and prevention activities.

There can be subspecalties in Paramedicine just like in many other professions; be they neonatal transfer, critical care transport, intensive care (ALS), speciality rescue (high angle, caves, swiftwater etc) etc etc but they all fall under the title of "Paramedic" just like you can have a private, commercial or airline transport pilot but he is a still a "pilot" just like all you Canuckistanadians have a 4 (or F in Ontario) endorsement on your drivers license; doesn't mean you don't still have a "drivers license".

Ambo's need to stop letting the bull take charge of them and take charge of the bull; need to get out from being owned by doctors and firefighters. There is one service provider here that has thier thumb so firmly up thier arse I wouldn't mind being owned by the Fire Service right now.

[CBEMT]

I've gotta find that 'net video I saw of an Italian EMS physician at the scene of a motorcycle crash.

[daedalus]

The Paramedic in the US is ideally a professional educated specifically to extend physician-like care to the scene of an accident or emergency. It is our specialty. There is no need to replace experts in out of hospital medicine (paramedics) with doctors or nurses. The need to go to the bachelor of science level is undeniable given our responsibility, and to insulate ourselves from a nursing profession attempt at gaining in on prehospital care (which could easily be done since they have the foundation education to do so). We should also look into making the ambulance the "paramedic's domain". We should take CCT back from the nurses and work on establishing ourselves as the leaders of transport medicine.

Call me idealistic, because I am.

[Kiwiology]

The Paramedic in the US is ideally a professional educated specifically to extend physician-like care to the scene of an accident or emergency. It is our specialty.

"Extend physician like care" makes ambo's sound like a doctor's bitch, hence, being subserviant to the house of medicine!

What about the other 90% of patients who do not have some emergent life threat?

Have you not been listening to me scream for pages now about how we need to get away from proving "life support" and do something about the other 90% of people that all the ambulance can do is take them to the hospital?

Look at ECPs in the UK (dubiously, no press please Professor Malcolm Wollard), CARE/ECP in New South Wales, ECP (urgent community care) here in Wellington, CREMS (community referrals by EMS) in Toronto.

Until EMS gets its thumb out its arse, away from the 10% of jobs that are "exciting" and takes the 90% of its workload which is not glamorous and exciting SERIOUSLY and develops appropriate linkages into the healthcare systems for these patients then I dont think it's going to get very far.

So ... a Paramedic should be defined as at the VERY MINIMUM a "health professional who provides emergent community based health assesment, treatment, referral and transport as appropriate to the to enable them to recieve the most appropriate healthcare for thier needs" or something VERY SIMMILAR

Edited February 14, 2010 by kiwimedic

[JPINFV]

Have you not been listening to me scream for pages now about how we need to get away from proving "life support" and do something about the other 90% of people that all the ambulance can do is take them to the hospital?

The problem is that that requires paramedic determination of non-transport, a concept that US paramedics have consistently shown themselves to be incapable of. It's kinda of like calling cardiac arrests on scene. It needs to happen. It should happen. However a few tards can't seem to get with the program and ruin it for the rest of us.