BLS vs ALS

[Kiwiology]

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.

Oh please don't tell me you still transport primary non ROSC arrests!

Could it possibly be that EDUCATION and KNOWLEDGE are the answer here???

[JPINFV]

Yes, there are plenty of areas where transporting non-ROSC arrests are common place, even if protocol allows requesting a field termination.

[Kiwiology]

Yes, there are plenty of areas where transporting non-ROSC arrests are common place, even if protocol allows requesting a field termination.

Honestly I don't see the point. In Circulation when Guidelines 2005 were published the AHA stated there is no point in transporting a non-ROSC arrest and I agree; except if the patient is hypothermic or has some problem the hospital can correct like cardiac tamponade .... maybe hyperkalemia?

Think of the risk of rushing lights and sirens through the streets, the needless time ED staff spend wasting trying to work the patient and the needless stress it puts on the family.

[JackMaga]

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 ?

Well of course a Family Practice physicians would have no education in prehospital care, why should he? He is not going to provide EMS care! Perhaps I wasn't clear but we are not talking about a system where any doc can hop on an ambulance just because he has a MD behind his name!

And yes, I think that a physician who has completed a 5 years residency in Emergency Medicine (which includes EMS care) is more educated than a paramedic with a 3 years degree. Whether this means that the outcomes wil be better or it will be cost-effective is subject to debate of course, and the benefits may be different from one healthcare system to another.

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

I can think of many istances where US paramedics care was reported as way less than optimal...

[JPINFV]

Honestly I don't see the point. In Circulation when Guidelines 2005 were published the AHA stated there is no point in transporting a non-ROSC arrest and I agree; except if the patient is hypothermic or has some problem the hospital can correct like cardiac tamponade .... maybe hyperkalemia?

Think of the risk of rushing lights and sirens through the streets, the needless time ED staff spend wasting trying to work the patient and the needless stress it puts on the family.

The problem is opposite of what you think. The problem is when paramedics declare patients dead when they have a heart rate causing the coroner to call 911 because the corpse is moving. I'm not defending the practice of transporting patients in cardiac arrest, but it seems like the same story, different location comes out every 2-3 months.

And yes, I think that a physician who has completed a 5 years residency in Emergency Medicine (which includes EMS care) is more educated than a paramedic with a 3 years degree. Whether this means that the outcomes wil be better or it will be cost-effective is subject to debate of course, and the benefits may be different from one healthcare system to another.

Where are you going to find these EM board certified physicians to begin with? There are still hospitals without board certified EM physicians and there isn't nearly enough EM certified physicians available to provide prehospital care in the quantity needed. Heck, there isn't even enough EMS fellowship or medical director trained EM physicians to provide a properly trained physician to every service that needs one. Now if we could get Medicare to start paying for a significantly more graduate medical education spots and throw a bunch of those into emergency med, it might be a possibility.

[Kiwiology]

And yes, I think that a physician who has completed a 5 years residency in Emergency Medicine (which includes EMS care) is more educated than a paramedic with a 3 years degree. Whether this means that the outcomes wil be better or it will be cost-effective is subject to debate of course, and the benefits may be different from one healthcare system to another.

We have a quasi-physician responder system called PRIME or primary response in medical emergencies for triaged life threatning emergencies. It is an exclusively rural program that intergrates the local family doctor (general practitioner) or nurse into the emergency response system if ambulance based advanced life support is > 20 minutes away.

I think this program is rather dubious because it really prevents the ambulance service from having to increase the number of Intensive Care Paramedics (ALS) but it does take advantage of a health resource in the local community which otherwise might go unutilised.

That was just a local perspective; but I don't really see the need for physician based ambulances except in the those jurisdictions where it is locally beneficial due to the health system operating modality or legislative restrictions where a physician is required for certian interventions; for example HEMS Doctors in the UK for RSI.

The problem is opposite of what you think. The problem is when paramedics declare patients dead when they have a heart rate causing the coroner to call 911 because the corpse is moving. I'm not defending the practice of transporting patients in cardiac arrest, but it seems like the same story, different location comes out every 2-3 months.

I know that everybody makes mistakes but surely asystole in all three leads speaks volumes?

[JPINFV]

I know that everybody makes mistakes but surely asystole in all three leads speaks volumes?

Rhythm checks? Naw... these are DOAs where a simple two finger pulse check was the deciding factor.

Edit:

I went through the past 100 links in the news section. The following links were found on pages 1, 3, 6, 7, and 9 respectively. 10 links per page.

http://www.emtcity.com/index.php/topic/17505-another-victim-survives-doa-declaration/

http://www.emtcity.com/index.php/topic/17269-yes-yet-another-death-determination-fail/

http://www.emtcity.com/index.php/topic/16304-another-death-determination-fail-by-fd/

http://www.emtcity.com/index.php/topic/15900-another-death-determination-fail/

http://www.emtcity.com/index.php/topic/15325-arizona-victim-thought-dead-not/

Edited February 14, 2010 by JPINFV

[Dustdevil]

What about you simply disband the idea of a separate profesional who provides medical care outside the hospital and make properly educated physicians and nurses run EMS?

I have no problem with that. None at all. So long as those providing the care are competently specialised in emergency care, I believe it is the best possible solution. I just don't think this country would ever pay for that because, unlike Europeans, we like to keep at least half of the wages we make, rather than paying them in taxes.

[armymedic571]

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

I don't think that you are going to find many here that disagree with you. I read the study and article that came out of the Toronto program last year. Amazing to say the least. It would be nice to see something like this in the US.

Actually, I could be wrong, but aren't there a few systems in Arizona trying this right now. Anyone have details?

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.

This is true and that's why it is tragic. Despite increased education. some of our cohorts and our Medical command mentors refuse to get with the times. I know of a very educated medic who will simply state his reason for transporting an arrest as, "that's the way I've always done it." Quite depressing actually.

Oh please don't tell me you still transport primary non ROSC arrests!

Could it possibly be that EDUCATION and KNOWLEDGE are the answer here???

It is. I also think US Med Command Docs, administration and management, need to allow their providers to make these calls. I know of several systems where these issues are micro-managed at the management/Command level.

The problem is opposite of what you think. The problem is when paramedics declare patients dead when they have a heart rate causing the coroner to call 911 because the corpse is moving. I'm not defending the practice of transporting patients in cardiac arrest, but it seems like the same story, different location comes out every 2-3 months.

Where are you going to find these EM board certified physicians to begin with? There are still hospitals without board certified EM physicians and there isn't nearly enough EM certified physicians available to provide prehospital care in the quantity needed. Heck, there isn't even enough EMS fellowship or medical director trained EM physicians to provide a properly trained physician to every service that needs one. Now if we could get Medicare to start paying for a significantly more graduate medical education spots and throw a bunch of those into emergency med, it might be a possibility.

Kiwi said it best. Education and Knowledge.

I find it Ironic. The best ER physician I know in fact is a Family Practice Doc and not EM certified. However, he was a Paramedic. Most of the EM docs we have are very risk adverse and will try to transfer something out or divert before accepting a potentially tough patient.

I know that everybody makes mistakes but surely asystole in all three leads speaks volumes?

I think where JPINFV was coming from, was that some medics are just that lazy. I apply the monitor even when it is obvious, mostly to have complete documentation.

I think it would be fair to say that we can discuss/debate this issue all day. In the end (at least in my opinion) it goes back to two things)

1. The National EMS model. We all need to be on the same page. Just like every other medical profession.

2. Increase not decrease education standards.

Edited February 14, 2010 by armymedic571

[JackMaga]

I have no problem with that. None at all. So long as those providing the care are competently specialised in emergency care, I believe it is the best possible solution. I just don't think this country would ever pay for that because, unlike Europeans, we like to keep at least half of the wages we make, rather than paying them in taxes.

Well that is a point worth considering... as I said, the cost effectivness of such a solution is highly dependent on the type of healthcare and welfare system that a country has... it will come easier to those that already have some sort of public funded healthcare.

Edited February 14, 2010 by JackMaga