Hypocritically Speaking – My opinions about EMS models and philosophies

The short version of my thoughts: it’s about triage.
There are times when it’s most important to begin ALS treatment on scene, times when it’s most important to transport, and times when it’s important to do both- and provide ALS treatment while rapidly transporting.
I don’t think you’re being hypocritical.
Besides being about triage, it’s about training, and it’s about tools.
I’m out in the middle of nowhere, where it seems that in some ways time stands still. A lot of the older people out here believe the ambulance is just a taxi with flashing lights, and will insist they “don’t need it.” Aunt Mabel will drive them just fine. I’ve explained to more than one person that the ambulance is like bringing the emergency room to them, that the medics can start treatment right now, rather than waiting until they drive to the hospital and wait there for what could end up being a long time before seeing a doctor.
The other big difference is that with our small hospital, sometimes, the care provided in the back of an ambulance is better than the hospital. I’m not knocking the hospital, it’s not a bad place, but they don’t get a lot of true emergencies. It’s not a trauma center.
I think the best thing that could happen to EMS is to look at the entire system and make it fit together better. Play to the strengths of each part.
Or, as the song says, you’ve got to know when to hold ‘em, know when to fold ‘em, know when to walk away and know when to run.

I know how you feel.  I support tiered ALS/BLS systems for several reasons, not the least of which are ALS skills maintenance vs over-saturation in all-ALS systems, and that some of the best cardiac arrest survival rates come from such systems.

But I also think that most BLS providers, given the amount of training they receive vs what is left out of their education, have no business decided what is and what is not an ALS patient- a key necessity for tiered systems.  I’ve had a rash of patients over the last year, including 2 STEMIs, that I think I would have under-triaged as a BLS provider, and that only with my ALS training and experience was I able to appreciate their true condition and treat them appropriately.

Hence, I feel like a hypocrite every time I advocate for BLS/ALS systems. 

I am currently on the dividing line between the EMS and physician communities (active EMT for 7 years and finishing up my 3rd year of medical school). Interestingly, this past year has made me question the way I approached a number of patients over the past 7 years while working on the ambulance. Did the young athletic patient who had a syncopal event that I didn’t advise against refusing really have a deadly cardiomyopathy? Did the patient with chest pain who had a normal EKG who we told was not having a heart attack really have unstable angina or an NSTEMI and end up in the ICU? I bring these scenarios up because of the advocation of treat and release by paramedics in this article. Although not the main concept, I felt that in the end this is possibly what the author was advocating. Paramedics receive approximately 1 year of training but yet have a scope of practice rivaled by few in the medcal arena. The safety mechanism which I believe allows this is that most patients will end up under hospital care in a short period of time and that paramedics must follow rigid protocols. Diagnosis and determination of whether someone is acutely ill is not something that can be done without a thorough understanding of the pathophysiology of all diseases within the differential diagnosis. Even with this understanding many times a determination cannot but made without the use of advanced testing available only in the hospital setting. Am I saying that the concept of a primary care paramedic is completely flawed? No I don’t believe so. However I feel there role should more closely mirror that of nurse care managers in PCP offices who focus on prevention and follow up rather than on triage of emergencies.

I think we’re splitting hairs here. If you look at what paramedics in the US were allowed to do 30 years ago it was rather limited, especially if you took away base contact. In some areas of the country a paramedics scope now far outclasses what RN’s can do. We’ve come a long ways. I think that we will continue to advance in our scope of practice as evidence based medicine keeps proving that we’re doing good and it fulfills a need. Let’s look at “their” system and take what works well and improve ours.

I’d be curious to see some hard statistics on our system vs theirs. You know, survival rates for STEMI’s, strokes, full arrests, trauma’s etc. I think that would be a great place to start the comparison. Once a difference is noted, figure out why. Who knows, the EMS differences may have nothing to do with any possible change in outcomes. There’s a lot of variables.

I believe triage is very important. Probably as important is the availability of training and support for a higher level of care in areas that could really benefit from a higher level of care. In an area of Idaho that I regularly work in there is one hospital that serves 2 1/2 counties and receives ground transports from up to 60 miles away in one direction. This hospital would double in size and staffing by moving into the neighboring veterinarians 10 stall horse barn. These counties total approximately 6000 total human population between them. These areas are serviced by 3 ambulances operated by 3 different volunteer fire departments. These departments require a first responder (primarily to drive) a basic and an intermediate to respond to calls. These departments provide free training to first responders and EMT basics and depending on weather and training schedule can take up to a year to complete each. Intermediates pay for their own training at one of the colleges up to 100 miles away. Their training depends on the availability of internship hours and contacts and can take 2 years to complete. In a rural ranching community it’s difficult for a person to justify that kind of expense in time and money. Upgrading to paramedic service would be an even bigger burden considering the average wage in the area is $8.00 an hour. Keep in mind also most paramedics are seen only in the big city fire departments and air ambulances. Also keep in mind that average initial response times can be up to an hour depending on if the required personnel are working in an area that their pagers will actually work. One example was when I severely cut my hand with a skill saw on a job site 4 miles out of town. 45 minute wait for the ambulance, 40 minute ride to the hospital, 20 minute wait for the on call doc to come from home. I was really glad I wore a belt that day and that EMT training kicked in before shock did and that there was good flying weather from the local hospital to the big hospital 90 miles away.

#preventionparamedic !

 Well said, Greg. The few studies done have pretty much all shown that paramedics are poor at deciding who needs to go to the hospital and who doesn’t. One of my former medical directors never worried much about an ALS crew sending a patient in via BLS because the patient was still going to end up in the hospital. He was far more worried about residents sending patients home where there was no medical care to be had.

Primary care paramedic bumps right up against the scope of practice of visiting nurses. If there is a need for that type of service, it more appropriately belongs to NP and PAs, not paramedics.

I wonder if in France they have as much nonsense calls for service given differences in healthcare and culture.  I have noticed cultural differences in using ’911′ within different area in which I work.  Some use it every time they get emotional or have a stubbed toe, others use it as a last resort.

In the end, a lot of it comes down to cost – benefit analysis.  What is the best use of resources?  Is putting doctors on the street to respond to BLS/ALS calls worthwhile given the cost and shortage of doctors?  What can they do in the field that well trained medics cannot do?  I think the system needs some improvements, but I don’t think doctors on the street is necessarily appropriate in most parts of the U.S.

Here are my 2 cents. I see why you advocate a Primary Care Paramedic program.. to remedy ER overcrowding among other things. I think that it would be costly to administer something like this. Lets be honest, there are alot of paramedics out there that shouldn’t be allowed to do half the stuff theyre allowed to do now. It would take LoTS of money to properly train a medic to do this. It would also take immense coordination and money to institute an EMR system for this as well. You think drug seekers are bad in the ER, just wait till you are allowed to deliver the drugs to them. Then they call another competing service out for the same thing and hkw would they know you just left there a few hours ago after “treating” them. As for triage, being an 8yr dispatcher, I would say (selfishly) that Docs belong in a clinical setting, not a 911 center. I think if we train all dispatchers as EMD’s and when I say that, I dont mean a 3 day class… I mean come up with an EMT like program taylored to provide first responder services via phone, we would be fine. I personally have had a couple of code saves via phone among many other things. I am also a huge supporter of a tiered response system using system status management and response protocols with a mix of bls/als/semv’s to get the job done efficently while being more cost effective. Thats just me though…