Reality Check

Who knows what calls are going to occur when? Either way we end up with ALS ambulances.

It is the level of care provided. The best level of care possible.

I may not know about the intricacies of all this ALS talk and medicinal treatment…but the argument that we don't need ALS is a dumb one.

ALS care has become a standard in most areas for the level of care provided. If you can get by with BLS on a call then so be it.

This is the same reason that firefighters don't drive around in pickup trucks to alarms…you never know when you will need the gear on the truck.

In my area, a lot of the medics also work in the hospitals. They understand the care that the pt. will get at the hospital and often will have blood drawn when we get to the hospital so that the ER staff can quickly do bloodwork if needed.

I think this whole discussion is working against were we should be going with prehospital care and that is forward not backward.

I completely I agree. Rather than taking skills away I think we need to focus on perfecting our current skills. What is the point in expecting a medic to get a degree if they can't do anything with it?

Timothy seems to think that degrees are a good idea, but using them is bad.

If he is not willing to move forward, we try to coax him. If that doesn't work he gets left behind I guess.

I am really not sure why we are even having this discussion. The last thing I would want to do is provide narrative on why you should get rid of my job (not that I am a medic) in general.

Rather, we should be moving forward…that is what EMS 2.0 is all about. And yes, it includes EMT's of all certifications!

It does seem a bit odd. The only thing I can see is that TImothy seems to have taken a few studies completely out of context to say that all ALS skills that are not life saving should not be used.

I can't find anything that says this.

On that note, I think that NO firefighters should hold any EMT certification. As obviously their job is to fight fires, not save lives.

Do I really think that, NO. But is that essentially the same argument?

Fire Critic, I'm not saying get rid of ALS altogether. I am saying don't provide prehospital ALS care to every patient.

“In my area, a lot of the medics also work in the hospitals. They understand the care that the pt. will get at the hospital and often will have blood drawn when we get to the hospital so that the ER staff can quickly do bloodwork if needed.”

Three paramedics at South KC where I've done ride alongs are also ER nurses. I certainty think being able to see what happens after the medics have gone home is valuable.

Degrees are for saying to an employer “hey I'm not as dumb as homeless guy Greg”

You perfect skills by practicing them. King County figure out that they could get highly skilled paramedics partly by not sending them to every call.

I don't think unnecessary prehospital ALS care should be provided by the more medics you have the less skilled and experience each individual one is going to be.

I think you are making some assumptions that are pretty hard to make. How do YOU know what is unnecessary? You have made statements that indicate that if they ain't dyin', they ain't getting no ALS. That is absurd.

Degrees prove nothing. At all. I use to work with 2 medics with degrees, wouldn't let them touch my family if I had to.

Your Logic about KCM1 getting highly skilled medics by sending them to less calls is seriously flawed. Even BLS calls make good ALS providers. It just doesn't work. Using that model is what services do to SAVE MONEY, not provide the best care possible. If the service was concerned about providing the best care possible, you'd have a lot better argument and I would be clapping you on.

Relying on dispatch and EMT-B's to determine if a call is ALS necessary is dangerous, at best.

Having inexperienced paramedics handling critical calls is absurd. I'm fine with an all ALS system if and only if the critical calls are handled by providers with lots of critical call experience per year.

Just because there is a medic in the truck doesn't mean they are getting ALS care. No one said that every patient gets and IV, Monitor, Drugs, etc. Running BLS calls is GOOD for medics to keep up on assessments. Running LESS calls will NEVER make you better at doing your job, outside of reducing stress. If you can't hack the stress of a few extra calls, you aren't going to be able to handle the stress of real ALS calls.

I can count a lot more ALS calls that don't involve Life or Limb events than do.

The simple fact is that between paramedic school and your FTO program, you should be able to handle the calls. If you can't, get out. Part of handling calls is knowing when you DON'T know what you are doing, and calling medical control.

My system uses a Senior Medic/Staff medic system. Every truck has someone who has been a medic for at least 3 years and has both FTO'd as a staff and senior paramedic.

Expecting paramedics to become skilled by only running the critical calls is not going to work. This is a model used to save money, and that is all. BLS trucks with ALS cars is used to save money in the payroll.

Individual paramedics in King County are getting more critical call experience than if paramedics were sent to every call.

“Relying on dispatch and EMT-B's to determine if a call is ALS necessary is dangerous, at best.”

You're right about that. Especially considering the private ambulance EMTs who actually transfer care don't get to say “hey I'm not transporting this guy without a medic eval”

More than 50% of calls medics do see in King County are non-critical and those calls are not the ones medics transport.

Firstly, can you explain to me exactly what you consider an “inexperienced paramedic” to be?

Secondly, what are YOUR credentials, including experience, to make blanket statements based on outdated (6 years+) studies?

It's one thing to make comments and observations based on experience, and something entirely different to make comments and statements based on ZERO experience. Doing a few ridealongs, or “knowing people” doesn't equate to experience. Reading studies performed in a specific geological location SIX YEARS AGO doesn't provide insight. Medicine changes on a DAILY basis.

Tim, (can I call you Tim? I will call you Tim.) I admire the fact that you want to change EMS. Great! But consider the people you're talking to, who have the experience, the PATIENT CONTACT, and the GUTS and COMPASSION before making statements based purely on someone else's SPECULATION.

KCM1 paramedics are running less basic calls and more serious/critical calls than the average paramedic.

Inexperienced paramedics are those who in a single year have only performed 3 ETIs, 30 IVs,… ugh no paper in front of me with the low numbers for a single-tier system

I have no credentials period.

Will do.

See, this is part of the problem, you need a paper to show you what is inexperienced.

Second, what kind of system is so small that you could have less than 30 IV's a year? I worked in a place with 360 calls a year and met this. I had 3 ETI's in that time too.

Further, you don't mention other ways to tune skills, like cadaver labs and surgery rotations. many services do this.

You are really relying on a “model system” that is really doing what it has to do to cut corners.

You realize that in order to become certified as a paramedic (at least in my neck of the woods) that you have to do a MINIMUM of 100 IV's, 6 childbirths, 20 intubations, 500 clinical hours in a hospital (not just the ED), and over 700 hours of riding with a supervisor, right? So by your definition, the “inexperienced paramedic” you refer to isn't even out of school yet..

OK I'm wrong. I was relying on a broken system.

Show me a place you can substantiate this claim.

I was referring to on an annual basis after supervised training. Look I'm wrong about this stuff. This debate has been very good for me because I'm learning how to accept and listen to different points of view.

Degrees are nothing more than a piece of paper letting the world know that you spend X hours sitting on your ass listening to someone tell you “this is how it's done”, and then passing a test (or a number of tests) showing you paid attention to what you were told.

A degree does NOT equate to experience.

For example: A job in my industry requires EITHER a 4 year college degree, -OR- TWO years field experience.

Imagine that?

Aw don't do that. You started the debate.

I can't. Game over for me.

I started the debate thinking I was right. I'm not.

“A degree does NOT equate to experience.”

I agree. I think college is somewhat pointless…

Right then, time for me to have a little say here.

Timothy, I know of you, you are spoken about at times in blogging circles and for your intitial attempts to do something with EMS 2.0.

I also know that you have had run ins with some of the other experienced medics in the blogosphere, and that is a shame.

Its a shame because you are obviously a passionate individual who wants to do good in EMS, but you HAVE to learn to walk before you can run. You have to learn that the majority of people who read what you write on the internet are also passionate people, and unlike you so far, have vast amounts of experience.

We are moving forward with EMS 2.0 and welcome all comments and opinions, but you have to be able to substantiate them with evidence, and best practice arguments for you to be taken seriously and more importantly become respected in this community.

Im sure the last thing you would want is to become known as 'that guy'.

Thank you for your input, but it may be a good idea to write a draft, then re-read it a couple of days later whilst thinking about the audience you want to speak to.

That doesnt mean you need to shy away from hard questions, just maybe put them in a better way.

Right then, time for me to have a little say here.

Timothy, I know of you, you are spoken about at times in blogging circles and for your intitial attempts to do something with EMS 2.0.

I also know that you have had run ins with some of the other experienced medics in the blogosphere, and that is a shame.

Its a shame because you are obviously a passionate individual who wants to do good in EMS, but you HAVE to learn to walk before you can run. You have to learn that the majority of people who read what you write on the internet are also passionate people, and unlike you so far, have vast amounts of experience.

We are moving forward with EMS 2.0 and welcome all comments and opinions, but you have to be able to substantiate them with evidence, and best practice arguments for you to be taken seriously and more importantly become respected in this community.

Im sure the last thing you would want is to become known as 'that guy'.

Thank you for your input, but it may be a good idea to write a draft, then re-read it a couple of days later whilst thinking about the audience you want to speak to.

That doesnt mean you need to shy away from hard questions, just maybe put them in a better way.

“Thank you for your input, but it may be a good idea to write a draft, then re-read it a couple of days later whilst thinking about the audience you want to speak to.”

Thanks for the feedback. I should be proofreading my posts better.

“That doesnt mean you need to shy away from hard questions, just maybe put them in a better way.” Will do. Thanks.

First of all, I want to thank everyone for taking the time to talk about this. I have yet to have a thread get this much conversation. Talking things out is the key to any forward movement in EMS.

This has been a very interesting discussion. I started this thinking I was right. I wasn't. Thank you for getting a lot more attention on it.

I just wanna add my experience (because i dont see right or wrong, just everyones opinion) – My company runs one paramedic and one basic on each truck. Dispatch doesn't decide ALS or BLS, the senior medic decides using our protocols. If the patient warrants ALS care, they are given ALS care. We transport anyone who wants transport. I think its a damn good system. Sometimes people who call 911 need emergency attention, sometimes they just need help, and I plan to be the one there to help, no matter what that help may be. We are all here for that main reason – to help. ALS/BLS shouldnt be an argument, it should be a right to the patient to get the best possible care they can get.

The only reason BLS/ALS was a debate because the community I live in is served by a two-tier system which is based on the argument that less paramedics equals better care.

In most areas around here, fd responds with BLS capabilities, we then arrive (usually a couple minute response time difference). In other areas, we are first on scene, in which case if we need help, we just call for back up. I can see the argument in smaller, rural areas, a two tier system could work, but it just makes more sense to me to staff a rig paramedic/emt, or even double paramedic, rather than two emts and a sprint truck with a medic…

What's your definition of “works”?

“An adequate achievement with positive or equal outcome where the means meet the needs.”
Some rural areas may not be able to afford to staff paramedics on each of its trucks, and also may not have the population to support it. I'm not agreeing that its the best way, just the most logical way for some areas in this country. This just isn't the case in my area – which is why I'm saying i don't see a right or wrong.

This conclusion is false. If you have 6 paramedics and 5 critical interventions, indeed someone is left out. if you decrease the number of medics to 3, you do not have 3 super medics, you have 2 patients not receiving advanced interventions. Simple as that. More calls and less medics does not equal higher skills. Take any system answering more than 100,000 bells with less than 200 paramedics on the streets.

Finish a 4 year pre-med degree and tell me it's worthless. What's worthless is sitting back on the bare minimum and hoping your call volume will train you. My 10 years here in SF is worth 50 years in most systems but i am not better for it. time on the street does not equal competency. But I can show you, on a fancy piece of paper, that I got an advanced medical education to base my limited Paramedic class on.
I have proven I have what it takes to absorb information over a 4 year period and apply it to my current role as a Firefighter Paramedic.
How often do I use the information from my statistics class? Whenever some study says I'm useless, I can find it's weaknesses.
When will Anatomy 205 help me? Everytime i have an assessment to complete.
And psych 105 might have seemed useless but when a patient is altered I can anticipate what part of their mind is controlling their thoughts.
I could go on and on about my degree, but you claim it to be worthless.
Finish the program, take your EMT at least, then come tell me what I've accomplished is worthless.

If Boston EMS had a single-tier system would their first pass ETI success rate be 60% instead of 79%?

FALSE again. They are running the same amount of ALS calls since the call volume has not changed. They simply see less BLS patients, which means less patient contacts than most Paramedics, meaning less actual experience.

oh so you had 15 central lines last year?

I've never go to get my EMT. FUCK EMS!

If you can't handle a little debate, maybe you really should pack it up. You decided to bring the fury and you keep being stubborn and sometimes rude. Just walk away. It is that simple. Now take that crap off my blog.

I agree that a degree CAN be beneficial. A degree does NOT mean you are qualified for a damn thing though. YOU are the only one that can do that.

No ofcourse not! That you wont get your EMT cert, now just run along with your tail between your legs.

You seriously have a lot of nerve. Someone who has never been responsible for the outcome of a patient treating members of this community like this is dangerous. For the same reasons I dislike emtdani, I am starting to dislike you.

If you can not handle a debate(and being told you're wrong) then don't start one. It isn't about YOU.

Tim it sounds like you have been on the receiving end of a bad deal concerning your EMS career. I personally think it should be a requirement to be an EMT for at least a year before you get to take a medic class.

This whole issue of inexperience is a non issue. Are some children born as experienced EMS professionals?

Everyone starts somewhere. If you aren't willing for them to run calls, they will never gain experience.

Everyone has run their first calls and learned.

I like a good discussion/debate, but we should really be spending our time working on more worthwhile discussions.

Thanks for jumping on this M3.

I'll admit, I did get a little hot over this topic, but I was pissed that he took what I thought was a private IM conversation and posted it to his blog and I find it frankly insulting that Timothy can dare criticize any of our ALS patient care without any experience.

The examples you mentioned, Zofran for nausea or Morphine for ortho pain are two simple ALS procedures that we can and should use to care for our patients. Thom Dick said, “They don't remember your medicine, they remember how you made them feel.” If we treat all of our patients with compassion, treat them as if they were family, then we are always doing the right thing.

And guess what? It takes a medic with ALS skills to do that right.

999 FTW!!!

[...] reading this go read Reality Check by Medic [...]

I knew there was a reason I don't shine my boots….

Walt! Missed you man! Been ages!

I knew there was a reason I don't shine my boots….

Walt! Missed you man! Been ages!

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