One of my biggest complaints in EMS education and practice is that too many providers take clichés from t-shirts and turn them into the dogma of EMS practice.
Two of these overused sayings are similar. “BLS before ALS” and “EMTs save paramedics.” And they’re two sayings that when the President appoints me “EMS Czar,” I will ban with the severe penalty of taking away your collection of EMS t-shirts and Galls’ catalogs.
My biggest concern is that many of the people who repeat these saying the loudest (because we all know that in EMS, loud=winning) are those who are BLS providers who don’t have ALS education. This is the equivalent of me spouting off that paramedics save physicians, even though I only have a vague idea of what happens in medical school or graduate medical education.
The realities are this. These cliche sayings are nothing more than feel-good t-shirt sayings designed to boost the ego of entry-level EMS providers. Furthermore, even a marginally competent paramedic doesn’t differentiate between BLS and ALS skills and assessment. They synthesize the knowledge they have along with their experience to create a holistic view of the patient and treat the patient as such. In the actual world, many patients, especially those with medical complaints require the assessment of a paramedic level provider, if not paramedic level interventions.
I fully acknowledge that there are some excellent EMT-level providers out there who are the exception to my semi-rant. These EMTs are primarily found in EMS systems where there’s an extensive field training and continuing education process that mandates a level of independent BLS practice. In other words, becoming a truly independent BLS provider ready to assume responsibility for patient care requires much more than what currently counts for initial EMT education.
But the sad reality in much of the EMS universe is that EMT education consists of little more than showing prepackaged PowerPoints, war stories, and some level of minimal competency. With that current paradigm, there’s only a small subset of patients who would benefit from BLS treatment without at least an assessment from a paramedic level assessment.
Ultimately, like much of medicine, and for EMS in particular, you don’t know what you don’t know. If you want to be trusted, the best recommendation I can give is to never be satisfied with minimal competence in the entry level of emergency medicine. Quit worrying about justifying what is really an entry level skill set — learn and grow to advance your knowledge, whether formally through a paramedic certification, or at least through formal and informal continuing education.
As most of y’all know, I tend towards blunt. Medicine is about helping people. And you can’t help many people, including your partner, if you merely meet minimum standards in the minimum level of certification to staff an ambulance. And this truth remains plainly evident no matter how much you cite cliches and stories that your instructor told you.
Reality is — we’re a team. We all have a role to play and much of the role of the BLS provider is to assist the ALS provider.
I’ll have to partially disagree with you. I do a lot of work with paramedics who seem to forget that the foundation of good ALS is a firm grasp on BLS skills.
Just to be clear, that doesn’t mean that I work with paramedics who don’t understand that. When I was a field provider almost all of my ALS co workers understood that.
What I do now is, as you know, mostly education and some remediation. As a result I see a lot of reports where the paramedic forgot to do the basic stuff before breaking out the expensive patient harming equipment.
Paramedics have to lead by example, and leaders they are. If EMTs see them doing dumb stuff, then the EMTs are going to think that the dumb stuff is what they should be doing.
In my many years in EMS, I’ve never worked with a good paramedic who wasn’t first a good EMT.
I think there is some historical context to this dogma.
Early in my EMS career paramedics were very rare. Most of us were EMTs and it was normal that there might have only been 1 paramedic on an entire shift. As such, basics functioning without an ALS provider was very common. Most EMT classes and all paramedic classes were taught by a physician. One of my mentors was the 17th paramedic in the entire state. Many of the medics were working having no senior medics to look up to. As such, like all new providers of any level including nurses and physicians, sometimes struggled to integrate their knowledge and performance. Basics (EMT-Bs officially) did frequently either do or remind these “new” paramedics about basic things they overlooked. I think that is still true today.
However, the knowledge and skills required to be a medic today are beyond anything that was even conceived back then. We were proud to identify V-tach on a LP5. Even the in hospital treatment for MI was basically waiting to see if the patient turned into a “cardiac cripple” or died. PCI was not even invented then. Paramedics had a few more skills and not a whole lot of knowledge above basics.
how many years has 12 leads been standard in EMS? 10? 12? I remember when CPAP was the cutting edge. I was there when providers were complaining pulse oximetry was consider superfluous. Not all services today have vents and etco2. The benefits of those beyond question.
The current curriculum requires understanding and mastery of topics most of the instructors I have met have no background in. Many students in many programs are basically self-learning this material from an extremely basic book with little guidance from instructors on why or even how it is important to actual practice. With an inadequate level of foundational knowledge, students are trying to memorize facts and concepts unheard of even 10 years ago.
Yes, they struggle. No, they are not proficient practitioners right out of class. Like the medics of my early days they are basically figuring out what to do with effectively no senior members knowledgeable or progressive enough to guide them.
A good metaphor I think is to have a WWI drill instructor train modern era army recruits and then send them to the field with no NCOs and expect them to have the responsibility of officers.
There is a massive disconnect and learning curve.
Contrast that to the modern EMT. Who has less knowledge, requirements, and responsibility than we had 24, almost 25 years ago. In fact, the modern EMT has less skills, less clinical time, and less hours of total education. In many cases, the same education as the medics minus a few psychomotor skills. (becoming a medic then was more about up-skilling than new levels of knowledge)
Be honest, aside from a handful of skills that basically boy scouts perform, there just isn’t much to EMTs. I know for a fact airline cabin crew has a more rigorous course over 4 days than EMTs in both flight physiology, assessment, and first aid than the most modern EMT curriculum because I teach it. The very first thing they are instructed to do is to ask for a higher level provider! Most of them are not comfortable after 4 days of my instruction (which without undue modesty is quality stuff) and they certainly aren’t using or even expected to use those skills on every flight. Though EMTs are expected to use their skills on every call.
By the time I went to medic school, I had highly experienced and knowledgeable guys not only teaching me, but showing me the ropes during ride times, during clinicals, and still when I was handed the keys to the truck and told good luck after a week of “orientation” mostly on filling out employment paperwork and billing, I struggled, as did most of us. That was coupled with the fact that many of us were paired with basics whose cards still had runny ink. As “experienced basics” and new medics we not only had to figure out what we were doing, we were expected to teach our new partners!
It is ignorant to think we screwed up any less or perhaps could have done a lot better. We cannot compare the providers we are today with what we were back then.
But in any event, Wes is right. EMTs no longer save medics. They can’t. Not because they are stupid or do not want to. Because the difference in knowledge today between the basic and medic is so profound. It’s like the model rocket guy trying to cover for a NASA aerospace engineer.
I predict the situation will get much worse before it gets better. For now I think we have to face the facts. It is just much harder to be a new medic today than it used to be. With both the traditional and technological hurdles, there will be more basic mistakes in the beginning. But we made it, and today’s medics will too; but the clichés of old, are no longer accurate and just reinforce an egotistical ideal that doesn’t match reality.
“foundation of good ALS is a firm grasp on BLS skills”
I’d argue against that. In fact, I’d argue that the whole ALS/BLS dogma needs to go away–it’s a distinction that is made only in the EMS world, and nowhere else in medicine. There are skills that are within your scope of practice and skills that aren’t, but I think the foundation of good ALS is an intimate knowledge of medicine, which will allow you to choose the right skills for any given patient–which are, sometimes, skills within the scope of an EMT-B. (I can think of dozens of conditions for which the most important thing to do is outside the scope of an EMT-B but within the scope of a paramedic. Yes, if you intubate someone whose blood glucose is 20, that’s bad–but all the airway and high flow O2 in the world isn’t going to help that person either; only dextrose is.)
I wonder why we still have the BLS/ALS tiered system? I’m not a lawyer, but I feel like if we removed the legality of BLS-only ambulances, it would force systems to pay for paramedics. Until they are forced to do that, those services will continue to use the cheaper option of EMT/EMR ambulances.
It feels almost negligent for these services to still exist. How do you accept responsibility for a patient without the full modern “toolbag” of treatment options? ALS is the standard of care. Just because you usually get away with not having the skillset and equipment on BLS transports doesn’t mean it’s acceptable.
How would you feel about an undereducated pilot flying your airplane? Yes, usually the autopilot works very reliably, but the pilot is trained extensively for when the unexpected happens. If it’s worth transporting (and competent providers should be able to identify otherwise), it’s worth transporting right.
You’ll get my Galls and 5.11 catalogs when you pry them from my cold, dead hands.