medic001918

The following is an article that I found over at www.paramedic.com written by Karen Powers. It's a pretty good read for someone just starting off in the field of EMS and might help to set the attitude in place from the beginning that educational opportunities are all around you all the time.

3/5/2005 Basic Survival: Succeeding in an ALS System p. 1 / 1

Face it. EMT-Basics are so far down the EMS food chain that you need a microscope to see them. I should know ... when I started drafting this article, I was a Basic! And as a Basic working for an ALS service, I developed a rather extensive list of positive affirmations for my own emotional survival. Repeat after me, "Everyone has to start somewhere," or, "I’m in Intermediate class." The affirmation at the top of my list was, "But I work with paramedics." That’s my story and I’m clinging to it!

by Karen Powers, NREMT-I

Opportunity Abounds

EMT-Bs working in ALS systems are often reminded about all the skills they cannot perform. No matter how lowly you feel—or are made to feel by partners with chips on their shoulders—you are right in the middle of opportunity.

First, as hard as it is to feel accepted and valued as a professional, you get to do, see and learn some pretty cool stuff. Not all Basics have this opportunity. In fact, many never have the chance at all—some by choice, admittedly, others by simple geography. An EMT-B working in a rural BLS or ILS service fulfills a role that is vital to the community but may go his or her whole career without assisting a paramedic on a call.

Second, if you consider yourself a paramedic-in-training and make quality skills and continuing education your priorities, you can climb the learning curve quickly and may earn the respect of your esteemed co-workers along the way.

You Are in Charge ... Really Meaning, you are in charge of your performance and learning. According to Pat Greenman, NREMT-I and EMT Mentor Program Coordinator for Ada County EMS in Boise, Idaho, common pitfalls for new Basics include poor operational skills such as navigating, chart-writing, and locating specific supplies in the ambulance quickly.

"Good Basic partners follow instructions well, perform skills quickly with quality, and anticipate their partner’s needs," said Pat. "They need to do whatever helps the paramedic get the job done."

EMTs always have something to learn from paramedics, no matter what. Even on shifts without a call, keep your eyes and ears open and you will find learning opportunities all around you. I do not recall a single shift as an EMT-B in field training that did not provide some little nugget of knowledge or inspiration.

Field training presents its own, unique challenge because someone is evaluating your every move. Pat recommends being open-minded and able to adapt.

"Each field trainer and paramedic partner have different teaching styles," he said. "If you are unwilling to accept feedback, you will have problems."

Exceed Expectations

Pat recommends that new and struggling EMT-Basics learn as much as they can to assist their paramedic partners, because Basics in ALS systems, he said, "are expected to operate beyond the scope they’ve been taught."

Once you are out of formal field training, the learning is up to you. Informal conversations with your paramedic partner can pack your brain with so many bites of food for thought that it is hard to turn it all off when it’s time to go to sleep.

Let’s get back to the professionalism point. If you consistently demonstrate professionalism and focus on doing your job well, you could be the ideal partner. According to Sarah Barber, NREMT-P and EMT Mentor for Ada County EMS, it is not the certification level but the skill level that is the hallmark of a good partner in the field.

"Quite honestly, some of my EMT partners are better at anticipating my needs and knowing what the standing written orders say," Sarah says.

Tips for Success

Look for other ways to contribute. If your paramedic partner is stuck writing charts for all the ALS calls you have run that shift, make sure you do more than your share of other duties.

Know your standing written orders inside and out. Slow shift? Review!

Seek out feedback and accept it graciously.

Listen attentively, even if your partner is simply venting frustration.

Maintain your professionalism at all times. Your patients, their family, and friends will judge your performance based on how they are treated, not their treatment.

Work hard and learn as much as possible. Be a model employee, whether you are paid or not.

Anticipate your partner’s needs as he or she is working with a patient. Stay focused and ask questions if you need clarification.

Additional Resources

Recently, EMS publishers have released two books for EMTs working in ALS systems. ACLS for EMT-Basics, published by Jones & Bartlett on behalf of the American Association of Orthopedic Surgeons, is easy to read and understand. I consider this book a must-read for any new EMT-B who volunteers or works for an ALS service. If you have some experience in an ALS system, you may find it too elementary.

In a more advanced presentation, The Basic Provider: Assisting with Advanced Life Support Skills, published by Elsevier Science (Mosby’s parent company) is spiral-bound and printed on card-stock as a comprehensive field guide. It is more detailed, so I believe it is more appropriate for EMTs with some field experience. Even Intermediates will find it informative, and it fills a good portion of the gap between EMT and paramedic training.

--------------------------------------------------------------------------------

Karen runs her own EMS website. Visit http://www.EMSresource.net.

© 2005 EMSresource.net

Shane

NREMT-P

Well, looks like BLS providers are not Paramedics in the USA, a shame I think u believe u are better then a BLS provider.

I'm not quite sure how to take your comment here. With regard to my abilities to manage patients and for procedures that are authorized through protocol and med control, I would say that I am more capable of managing a patient than a BLS provider in the United States. I can't speak on the Canadian EMS system as i have no experience or in depth knowledge on the matter. This feeling has nothing to do with a feeling of superiority, rather it has everything to do with scope of practice and more importantly education. In some calls, there is no difference between an ALS provider and a BLS provider with regard to the management of the patient. In the case of a patient having a hypoglycemic episode or altered mental status of some other nature, an ALS provider would be much more qualified to handle the call. This includes BLS management of that patient, and the potential ALS management. It's great that you passed the NREMT-P program. I have too. What's your point and what are you getting at? And you're right, a paramedic isn't a BLS provider in the United States. A paramedic is an ALS provider, inclusive of the complete BLS scope of practice. We're certainly entitled to have differing view as we seem to here. I don't feel that glucagon should be in the BLS scope of practice, and you'll find others that agree with me. You will also find others that disagree with me. I'm okay with it. I don't feel as though I have anything to prove to anybody here.

Shane

NREMT-P

Becksdad,

In simple terms, you got it. Also, when it's not working or in the time it takes to work there is the potential for other complications to arise that are best managed by a paramedic. Good work for understanding limitations.

To others,

A simple search should yield one all of the information that they desire on the glucagon/BLS debate. We don't need to rehash that once again here as well in this thread.

Shane

NREMT-P

Noone's asked you to defend EMT-I's. That's a topic that's been discussed many times over and always turns into a lengthy thread. The general concensus of many posters here that have any real experience is that the EMT-I program has a very limited application in pre-hospital care. That's not a new thread, and noone has asked you to defend yourself or your certification level. You do what your protocols will allow you to, weather we agree with them or not.

This thread was about professionalism, and that does include the appearances of personnel. Showing up in street clothes all the time and have no uniform policy really doesn't speak highly of your organization. The care they provide might be acceptable, but their policies sound like they need to be updated. Until we represent ourselves as a professional group of people in education, presentation and appearance; don't expect the rest of the healthcare industry to take us a professional group.

Shane

NREMT-P

And yes I have showed up on runs in my PJ's. My OSU fleece PJ bottoms as a matter of fact. But I don't think the woman who ran her car into a tree really cared what I was wearing. She was just thankful that we showed up to help her. Honeslty if you are having an active MI do you really care what the EMT and medics are wearing?

I'm curious about what your department has for a policy regarding uniforms? Is it commonly accepted to violate a policy? While your patient might not care about what you're wearing, the rest of the healthcare community is basing opinions of EMS as a whole based in part upon what they see. And if they see people coming to the hospital in PJ's, then they certainly aren't going to take us seriously. Also, out of curiosity if you're responding in PJ's how are you identified from a bystander on scene by other personnel (possibly from other agencies)? Something to think about with regard to appearances.

Had it not been for the volunteer FD and EMS I dunno what would have happened.

I'll take a stab at this one. My guess is that if it weren't for the volunteers your town would have some contract established with another service (commercial or otherwise), or possibly have come up with the funding for their own paid staffing of the ambulance. This would mean that you still would have had an ambulance show up to your car accident and you still would have been treated. Most likely, this would have been a crew ready to roll out the door at any time. The final guess to this one is that the end outcome would not have changed at all.

However, I will rarely agree with someone who is totally against volunteer systems, I've seen them save too many lives that otherwise would have died waiting. But I've heard pt's dying because it took the volunteer system too long to get there, or they didn't get maned.

So why would you rarely agree with someone who is totally against volunteer systems? There is no conclusive evidence that these people would have otherwise died? I'm reasonably sure that there would be some form of emergency medical service in place? My guess if you wanted to compare response times of paid vs. volunteer services; you would find that the paid services hold to a more consistent standard. When you're paying someone to be there, you are guaranteed staffing. You won't be holding an ambulance waiting and hoping for another crew member to respond.

Since this seems to be going down the volley vs. paid route again, I just fingured I'd add my 2 cents. There was a case recently in my area where a guy went into cardiac arrest. The volley FD was able to get 3 members to the scene in less than 6 minutes. The FD does not have an ambulance because they are in a paid system. They waited on the scene for over 20 minutes doing CPR and shocking with an AED. The paid ALS crew finally showed up and took the pt to the hospital where he was pronounced in the ER. No way to say what the outcome would have been, but if they volleys had their own ambulance they could have had the pt off the scene and at the hospital much earlier.

I'm curious as to what the delay was from the paid ALS crew? Is it a commercial service? a county service? If the town maintained their own transport service, they would have tighter control of response times and delivery of resources to the scene. It's much easier to come down on people to ensure tight standards when they're getting paid. I know of many volunteer services that are afraid to come down on members for fear of them no longer being involved. People are less likely to take a gamble with their livelyhood.

Shane

NREMT-P

I am looking for a good site to find some in depth info on the Fick Principle

Any site that we might have that would contain this information is the sames one's that are most likely obtained through using different search engines commonly available on the internet. As far as some "in depth info" goes, what exactly are you looking for? If you ask a broad question, you'll get a broad answer. It really is that simple.

And there have been quite a few students looking to forum members to do their work for them...it gets old sometimes when the answers are easily obtained.

Shane

NREMT-P

It's amazing how this post has gone. But now it's time to chime in myself on the issue.

Asys, great post. That's a great snapshot of what can be accomplished. I'm sure he didn't intend it to be a business plan for those who are questioning the feasibility of it; rather it's there simply to illustrate a point of what can be done when you plan things out and when you break things down to a per person basis.

As far as the little town of 100 people not being able to afford it. I'm guess that they manage to pay the other officials in their town? They were able to raise the money to purchase a fire engine and an ambulance. With the prices that many new vehicles are getting now, they should be able to look into a means of raising the money to pay a staff? Or better yet, since most small towns are surrounded by other small towns that combined might not have an overly high call volume; why not combine them in a regional or county system? Let a handfull of towns absorb the cost of equipment and staffing? That just might work. It might not be quite as fast as of a response (depending on the call location and location of resources), but then again it could be just as quick even with a greater distance to cover due to there people there dedicated to respond isntead of having to leave work, get to the ambulance and then arrive on the scene? I'd be curious to see how the response times would average out in that scenario.

As far as volunteer's go, and those described not appearing professional or acting professionaly; unfortunately there are those people in every field. And in EMS, they happen in paid services and vollie services. The issue with volunteers impacting EMS as a profession and not a hobby is that it's hard for someone doing this as a career to demand better wages or benefits when you have many others in the field willing to take your job for free. That goes to the basic supply and demand concept. If people weren't volunteering, the towns would be forced to obtain the means of paying for EMS. This would allow us to negotiate a fair wages and benefits package. In Connecticut, the majority of EMS is provided by volunteers (although more services are starting to pay people). In fact, my full time spot is as a paid contract paramedic (through a commercial service) to a volunteer service (which is considering going paid in the future). This gives me some more insight into the paid vs. vollie issue. I have seen some of the issues as far as staffing go. Some volunteers don't see the harm in booking off of a shift at the last minute leaving the town to rely on their backup coverage from the commercial service. This causes response problems, as well as a loss of revenue for the service which they depend on to cover operating costs. If the vollie service isn't transporting, they aren't getting any financial recovery on the job. So now someone books off a shift at the last minute and leaves an opening in the schedule that can't be filled. Can you discipline that person? Are you going to suspend them? You could, but what do they lose? They have no financial loss or reason to stay dedicated to the service. In theory, with paid personnel you can expect a reasonable level of staffing (since many people can't afford to lose money by not showing up to work). The other problem with volunteer services is that since people aren't doing this full time, they don't want to put in a great deal of time to be able to participate. This limits the training requirements that you can enforce. If you were to be a paid service, with adequate compensation you could expect to see higher salaries like those that are found elsewhere in healthcare. A higher level of education yields higher salaries which in theory would yield more interest and more providers looking for something other than a hobby. It's a vicious circle with a tremendous startup cost for a service to take on. However, once taking on the higher cost they could expect to see an increase in the efficiency of their day to day operation.

Shane

NREMT-P

First of all, good luck to your husband in overcoming the issues with his back.

And now on to the topic at hand. I have to agree with others. There's no reason that a service should have to make accomdations for someone who is not capable of doing the job itself. A requirement of this job is having the ability to lift and move patients. That's just to start. There are countless tasks that are physically demanding in the job as well. Ever been on a scene and had to move things to get to a patient? Ever carry a cardiac monitor and/or ALS pack (since they tend to be heavier than BLS packs)? CPR is demanding on the back when you're bent over for a prolonged period of time. What if a patient becomes combative and needs to be restrained? Is he going to sit there while his crew handles the situation? Is he going to be a liability to the service should he injure has back again on the job?

In a time where many volunteer services have a problem staffing a truck with two EMT's, it's difficult to ask them to wait until they can obtain a third rider for the call. This is especially true when the ambulance becomes legal with regard to staffing once there are two EMT's on board. I wouldn't want to be the one having to explain why the truck (which was staffed legally) didn't roll to the call because someone on the truck wasn't qualified to operate fully on the job.

Your husband's situation is unfortunate, but it's difficult at best to accomadate someone who can't perform all of the functions required for the job. It's not fair to the other members on the crew and more importantly, not fair to the patients who are waiting for help while a truck that's legally staffed is unable to respond. The lack of ability for your husband to meet the physical demands of the job would be enough for me to not want to work with him regardless of what kind of EMT he may be.

Just something else to think about, would you expect a fire department or police department to make the same accomodations that you're asking of EMS for your husband?

Shane

NREMT-P

We typically don't do carotid sinus massage in the field due to the possibility of releasing a carotid bruit and having an embolism floating around. If you are going to do CSM, you are supposed to listen with your stethoscope prior to the procedure to see if you can hear a bruit. The traditional method in the field is trying to have the patient vagal themselves down prior to using drug therapy.

Shane

NREMT-P

Assuming that the patient is having chest pain, and it doesn't appear to be a right sided MI (determined w/EKG), and that the patient has an acceptable blood pressure, I will generally allow one dose of NTG prior to the establishment of an IV. If the patient is hypotensive or on the lower side of normotensive, I'll often hold off on the NTG (remember the JVD, hypotensions and clear lung sounds can indicate right sided MI). I have had patients that have had rather large drops in blood pressure with the use of NTG. And I have been able to bolus these patients back to an acceptable blood pressure to continue with NTG treatment (the patient was not having a right sided infarct).

It's a grey area, and one that every provider will have their own answer for. I feel much more comfortable giving NTG, especially repeated doses; with an IV line in place. This way should the patient deteriorate, I already have a point of access and means to start to correct the situation rather than being caught behind.

Shane

NREMT-P

Sounds like a bad deal. Unfortunately, as a new hire at most services you have a probationary period which allows the employer to terminate the relationship at any time for pretty near any reason they choose. I know one of the services I work for is union, and the union can't step in until you're off probation. Move on and find another service. Hopefully there's other's around you. Good luck.

Shane

NREMT-P

If it wasn't for us "jolly vollies" they would have no one.

It's funny that if you didn't volunteer your EMS time, that they'd have noone. But many towns find a way to fund a police department or a fire department (for some towns). If you stopped volunteering, you can rest assured that these people would find a way to fund their emergency medical services. As far as a commercial service charing a lot of money for the services rendered...they're entitled to make money as well. It's supply and demand.

The strange thing is that emergency medical services are like an insurance policy in the sense that you don't know how good or bad yours really is until you need to use it.

I'm siding with the fact that eliminating volunteers would go a long way towards bettering the profession as a whole.

Shane

NREMT-P

Improve hiring standards for paramedics.

Improve education for paramedics.

Make everyone a paramedic.

Banish volunteers.

Pay us more.

That should do it.

While not being the total solution, I do like what's being proposed here. Great thoughts.

Shane

NREMT-P

I can understand where you're coming from about not the legal aspects of not following protocol. But the bigger thing to remember is that protocols are guidelines and not absolutes. Even as a paramedic, if a doctor gives me an order that I know is wrong but I choose to follow it anyway and harm is done to the patient, I'm just liable (if not more so) than if I didn't do it. We still have an obligation to do what's in the best interest of our patients. In the case of an unconcious diabetic, there is significant risk in placing a thick gel into their unprotected airway. The risk of aspiration becomes a very viable complication that needs to be considered. If you don't give the oral glucose, you might be answering questions to someone. If you give it you might be answering questions. I think that you're best option would be rapid transport or intercept with an ALS provider capable of correcting the situation. There's too much potentital to worsen the situation otherwise.

Shane

NREMT-P

Just because it's in a protocol doesn't mean it's right. That only goes to show that protocol monkeys shouldn't be operating prehospitally (not calling anyone here a protocol monkey...just an observation). Sure, your protocols may allow something. But we're supposed to be smart enough to know better. And this is one of those cases where we should know better.

The absorption rate of oral glucose is not fast enough to affect any realistic change in a diabetic patient who is unresponsive. Plus, as was mentioned, placing substances in the mouth of an unresponsive patient only invites disaster.

What's more, it was a NUTRITION teacher who said this. It wasn't someone who has been presented as having any credential to teach people how to deal with unconscious diabetics. Didn't that strike anyone else?

There are better ways to address an unresponsive diabetic. They usually involve transporting to the ED (from a BLS perspective) and/or ALS intervention. They do not involve stuffing oral glucose into the patient's mouth.

-be safe

+1. Well said. There really isn't much more to add to this.

Shane

NREMT-P

Squirrel killer:Thanks for that huge paragraph of "I've seen worse than you" experiences and absolutely nothing for advice....I think the easy advice is CISD. Cute screen name...

Somedic

+1. I have to agree that the advice of CISD could have been given without mutiple stories in a single, difficult to read paragraph would have been fine. As far as CISD goes, I thought it was federally mandated (maybe it's just a state thing?) that an employer has to offer you CISD or the benefit of speaking to someone at no expense to you for a job related event. I know Connecticut has it set up, but I really thought it was federal. So for your employer to not offer CISD would be rare, and they should offer another means of you speaking to someone.

As far as the call goes, it's one of the hardest to deal with. If you feel you did the best, that's all you can ask for out of yourself. Bad things happen to good people and that's just how it goes sometimes. In time, things should get better. Good luck in talking to your employer. I hope they will work with you to get the closure you need.

Shane

NREMT-P

I have seen some uniforms that have lime green plolos. I like the color, however, I think if you work in a city (I live in southern Ohio AKA no man's land) lime green may act as a big target. Speaking of city EMT's and medic's.....my hots off to you for being able to work under such stress. My ADD kicked in again....sorry. I'm going to stop talking now lol

Thanks for the compliment towards city providers. But the stresses of the job are the same. I work in both a city setting and outside of th city. The job is essentially the same with all the same stresses. The biggest change is the call volume. For the most part, the people who are using the 911 system are the same regardless of where they're located. It's just statistics as far as the nature of calls and call volumes go (there are exceptions to this rule). In my opinion, the biggest difference between the two environments is purely call volume.

Shane

NREMT-P

Two of the three services I ride with use these systems and they work well. I have no complaints. They are speed and maneuver based. The thing with these systems is that they must be calibrated properly to be accurate. I've worked with them for four years now and have no complaints. If you drive with due regard, they don't go off that often. And once you learn to drive with them, you can still make good time getting anywhere you need to be.

Shane

NREMT-P

The search function is your friend...and if it isn't, it should be. This is a topic that has been beaten to death on more than one occasion on these forums by very experienced providers. Please search and read the answers to your questions. If you still have questions after that, we can try to answer those.

Shane

NREMT-P

LMAO to urbandictionary!!!

Do these people pay (them selves) for all those lights?

More often than not, yes they pay themselves.

Shane

NREMT-P

The transport decision wouldn't have been an issue had they gone in with police presence in the first place. As others have mentioned, there's a number of problems with this call. Why would you talk your way into a potentially dangerous situation w/o police present? Why would you stick around when people are getting violent? Especially when it's a group of people larger than the group of two you came with (yourself and your partner)? And I would be asking for a new partner if my partner left me with a patient that's already been getting violent and where violence is threatened. If they want to roll the dice and see what happens to themselves when they push the issue, that's one thing. Don't risk my safety for your stupidity.

Once they showed up and they were refused entry, it's time to wait for backup to show up before doing anything. All in all, a poorly run call no matter what the experience level of the provider was.

Shane

NREMT-P

Both should be charged with reckless endangerment. The FF for driving excessively fast with his damn family in the car, and the cop for hitting a damn minivan with an idiot running emergent behind the wheel.

I think we need to be careful using words like "running emergent" in this case. Should we even be running "emergent" with our families in the vehcile? If he was in his POV, I'm assuming his flashers (as described in the article) to be his standard four way flashers. This is in no way an emergent response. Even if he was running an emergency light in his POV, they are deemed courtesy lights (at least in CT) and don't give the driver of a vehicle any authority to violate a single traffic law. If he was doing 85 in a 55, that is reckless driving and if a trooper was trying to initiate a traffic stop and he failed to stop then he was evading the officer. The officer did go to extreme measures to end the pursuit and that issue should be addressed as well. The officer may or may not have known who else the guy had in the vehicle with him.

80-85 MPH becomes to fast (legally) when the speed limit on most interstates is 65 (maybe 70) in some areas. Assuming a speed limit of 65, he is traveling +/- 15% over the speed limit. In Connecticut, anything over 20 MPH over the limit and you may be charged with wreckless driving which involves a mandatory loss of license.

I don't condone the actions of either of these guys, but the officer at least had a reason to try to initiate a stop.

Shane

NREMT-P

My doctor said that since there isn't any light duty, and would lose the income, that I could work as long as I felt comfortable. I need the money but it is already much harder to lift. I'm at 25 weeks right now. So my question - how long should I lift for? What have been your experiences and have you had any complications from continuing to lift our not so light patients?

Why not change the question that you're asking your doctor and ask him at what point (if any) all of the additional lifting could pose a potential harm to the baby? Unfortunately, many places don't offer much for a paid leave of absence when someone gets pregnant. These are all things that need to be considered before (ideally) someone becomes pregnant to make sure that they can handle the additional stresses.

Congrats and good luck working with your company and your doctor.

Shane

NREMT-P

We can agree to disagree and I'm okay with that. But once someone that is a medic now has as many years in as some of these other people, then they'll be making more money without continuing the education process. It's just the nature of the animal so to speak. My past partner was an EMT with 22 years in on the job with the same service and his pay was just under what mine was. I didn't complain that he was so close to me. I understood that if I had 22 years in on the job as a medic, my pay would be vastly superior to his. His time on the job was an equalizer; not in terms of skill, education or otherwise but strictly in pay. If someone sticks with the same service for all of those years, they'll be making the "big" dollars. So let's ask another question; should there be a cap on how much someone can make in a given position (so that they forego an annual raise once they've hit the peak)? That would prevent an EMT (regardless of experience) from ever making more than an entry level medic?

The nurse used in your analgy would most likely be making more money than a newly graduated nurse (regardless of additional education) had that same nurse stayed w/the same hospital for the amount of time. The incentive would be that a newly graduated nurse might start at a better base pay than the "old" nurse with the understanding that their pay would increase on a sharper scale. Once they have the time in, they would be making the money as a 10 year medic than a 10 year EMT due to their base salary being higher than that of an EMT to start with.

Shane

NREMT-P

Well I can understand your frustration, don't forget that if someone has been with a service for a long time and gets an anual raise their hourly wage is going to go up. If they've had a long time as a head start, they will be close to, if not higher than your hourly wage. In time, you'll be making the big dollars. Would you stick around working for a company if they told you that you were no longer eligible for a raise because you would make more money than someone with a higher level of care/authority than yourself? My guess is probably not. You'd be ready to walk out the door. You shouldn't worry so much about what everyone else is making. You should be concerned with if you can make ends meet for your family on your salary.

While basic theory is that a medic should make more than an EMT, people should be rewarded for longevity. Is it fair to my supervisors that as a road medic I have the opportunity to make far more than they do per year (they are salary)? After all, they are in a position of higher power and assume a larger role of responsibility? It's just how it is. If you're unhappy, maybe you need to find a new job that has policies and procedures more in line with your views?

Shane

NREMT-P