armymedic571

You're basically arguing as to whether you define an assessment by the tools used in that assessment or by the use of information gleaned from use of those tools. I argue that it is the use of information and the knowledge of which tools to use that makes the ALS assessment different.

Wendy

CO EMT-B

NO, NO, NO....

I am trying to say that the tools are just that. TOOLS. It is the art of the assessment, the physical hands on of the patient and interview that are the important points.

It is a fact, step by step, the patient assessments are the same. MY POINT and the bottom line, is that education does make the difference. (Funny how we seem to be arguing the same point! )

I have attached two skill sheets from NR. One BLS and the other ALS. They are (except for diagnostics) the same.

Patient%20Assesment.pdf

patientassessmentmanagementmedical.pdf

Maybe I misunderstood your question. If you're specifically referring to the physical assessment only (or physical + hx), then that's a separate story and I may not especially disagree. To me, "assessment" means the entire scope of information-gathering tools available to the provider, from his eyeballs to the machines with dials and lights. There's no particular difference between palpation and blood glucometry, except that some people can get in trouble for doing one of them. All just info and all part of the assessment.

And as you say, anyone can either take the information gathered and use it meaningfully, or be without a clue as to its significance. But again, to me, that's not part of assessment; that's part of diagnosis and treatment. I should be able to "assess" a patient and hand you a paper with everything I learned on it; you could then use that data to diagnose and treat, and we've done separate jobs.

Obviously the two parts usually go hand-in-hand and should interact. But nevertheless.

But maybe this is a digression.

Sure. But the significance of the pulse is largely as a way of viewing cardiac activity (the rest of it is probably as a measure of vessel compliance and distal circulation at that extremity, and an indirect look at BP). The medic and the Basic can both take a pulse, and both probably should; but the Basic can't do anything more (except perhaps auscultate for a rhythm, which is of marginal utility to him). The heart's electrical rhythm is a piece of information he will forever lack, no matter how "good" he is at assessment. Likewise, rhythm is something the medic can and will obtain, whether or not he's able to parse its significance.

Like I said, getting the information and using it are different skills. Getting it as part of the assessment. Using it (whether to treat, or to inform transport decisions, or to form a working diagnosis, or anything else) is something more and something separate.

Agreed. Fair enough then.

I think it depends on what do you consider sick/not sick to be... if sick/not sick means unstable/stable as in recognizing a near arrest patient in respiratory distress thatt needs immediate ALS care, or any other immediately life treating condition then yes, I think a BLS provider can and should be thaugh what to look for; however usually it takes only a visual primary survey to recognize such critically unstable patients so that the assesment a basic need to do is really well... basic! For example there's no need to palpate an abdomen or auscultate lung sounds to make a decision between critical and not critical.

If, on the other side, by sick/not sick you mean be able to recognize, based on your physical evaluation and history, that a patient, while stable, is suffering from a condition that might make him deteriorate within a short time (for example recognizing the presentation of a possible polmunary embolism in an otherwise healthy young patient with dyspnea and chest pain) then no, I think most basics will not have a clue... they might tell you what they're seeing if you ask them, but usually don't appreciate the significance of the signs they arere reporting, nor their relative importance.

So, if I understand you correctly. You are saying that although a BLS provider could go though the steps, that they might not appreciate the subtle clues that are present, as a more educated, more expeienced provider would?

I really think that you can't gloss over the above.

I realize you're trying to emphasize the education gap, as par for the course around here, but the fact remains that a Basic provider could literally be a FACEP in his day job, and a medic could actually be the world's biggest idiot; the first is NOT going to be able to truly assess to the level you're looking for, and the second may very well be able to, even if he's too dense to put it all together.

I CANNOT feel a pulse and tell you a patient's underlying cardiac rhythm or abnormalities. It is literally impossible. I can GUESS, depending on regularity, rate, and strength, and correlating with history and other presentation, but even if it's seemingly a gimme (A-fib, say), it will still only be a GUESS. The medic who runs an ECG can, if he is not brain-damaged, tell me what rhythm the patient is in. The fundamental difference between us is that he can use that tool and I cannot.

So I grant that the underlying assessment follows the same path, and is looking for the same things; but there is a certain level of clarity that is simply unavailable without the appropriate diagnostic tools, and in some cases that level is the critical one for recognizing conditions or narrowing a differential from meaninglessly large ("sick") to useful.

How exactly am I glossing this over? Seems some here are coping out over the inability to do a patient assessment. (Not you specifically. Please don't be offended)

I don't like your analogy. I am talking about the physical assessment. I think you are putting too much emphasis on the diagnostics. Besides, if the Medic was as stupid as you say, he/she wouldn't know what to do with those either.

I also don't like the pulse comment. All providers are taught to check a pulse. Is it present? Stong, or weak and thready? Regular or irregular? At that point who cares what the rhythm is, we are trying to determine adequacy in perfusion.

Thanks for the feed back. I really do appreciate it.

I voted that assessments are different with 'skill level'. It is really quite simple.

Education is honestly the difference between the assessments. Generally speaking, the more educated and/or more specialized the provider, the more detailed and conclusive an assessment should be. The more you know about how the human body works, the more you can suspect and assess for illnesses. Sure, the actual act of hands being placed on a patient may be similar between license levels, but the depth of the assessment will not be the same. How many Basics do you see perform assessments of the heart tones and cranial nerve exams? How many paramedics do you see perform assessments of tendon reflexes? The list can continue right on up the ladder. What is next, are we going to say that paramedics and nurses perform the same assessments?

Someone said it in another post, but it applies. How can you assess for something if you have no idea it even exists? The quality of the assessment is dependent on the depth of education.

Matty

Matty,

Thanks for the honset reply. And of course Paramedics and Nurses don't perform the same assessment (Nurses would have to go back to school)

Just kidding .....

BLS providers, by and large, are NOT taught critical thinking skills. Nor are they taught much of anything else for that matter.

I think the difference is that you may do the same actions within an assessment, or many of the same actions, but if you can't interpret what you're taking in, it doesn't make a damn bit of difference. The assessments are different by virtue of being able to interpret information differently. I don't view the physical skills of assessment as "the assessment" nor do I view history taking the same way as I did as a brand new uneducated Basic. My assessments are VASTLY different now than they were previously, so I stand by what I said in my previous post. They are different assessments.

Wendy

CO EMT-B

Your first sentence is a little harsh don't you think? If your basic providers are that bad. Then...

Your second statement is more towards what I was getting at. But, what has changed in your assessment? The steps, or the way you interpret the information you find?

Thanks again... .

I'm not going to insinuate anything here. I'll flat out say that there's very little foundation material in EMT-B training to do anything but crude inferences and rudimentary DDxs unless serious extracurricular education is sought. You can't think critically about pathologies that you don't know exist.

I am not disagreeing with you. My original purpose for starting this thread was to highlight that despite the fact that the actual step in the ALS/ BLS assessment, besides diagnostics are exactly the same. That BLS providers do not have the base level education to properly allow formulation of differentials and treatment modalities.

Even more, patient assessment is part of the providers differential diagnosis reasoning: basics don't have the fundamentals to do a proper diagnostic reasonig since they lack all A&P, patology and so on, so even when they're assessing a patient I don't think they really know what they're looking for...

As above. However, I would agrue that a BLS provider who does a complete and thorough assessment should be able to formulate a general impression between "Sick/Not Sick".

You need education in the basic medical sciences to synthesize information obtained from a history and physical exam and turn it into a working diagnosis. While an EMT and paramedic might both notice unilateral leg swelling and warmth, only the paramedic will be able to come up with a list of possible pathologies. What about cardiac and lung auscultation? What about a cranial nerve exam?

Also as above. Lung auscultation is part of the assessment. But once again, the lack of education might prevent the development of differentials, or treatment modalities. But formulating a good general impression between sick and not sick. I am not fully convinced.

I feel that if a BLS provider does a complete exam, they should at least be able to tell the ALS provider that the pt is sick, unstable. They may not know why or how (goes back to education), but know enough to say that all is not well on the Eastern Front .

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.

I perhaps an delinquent in my ALS survey ... any left over sand/dust in your shorts chafing can be very irritating.

A very good point ... look to the French experiance with Princess Diana ... an MD on board may have been a complication in a delay of transport, although who would actually know ?

cheers

Now that's hilarious . Are you saying that I am irritating?

The original post I saw was all rearranged. Genius.

Jeff

I'm not going to insinuate anything here. I'll flat out say that there's very little foundation material in EMT-B training to do anything but crude inferences and rudimentary DDxs unless serious extracurricular education is sought. You can't think critically about pathologies that you don't know exist.

I am not disagreeing with you. Just wanted some clarification on her post .

ps: armymedic571 Get out of the sun its affecting your sense of ha ha.

cheers

Ahhhh, that's not true. I thought we were trying to have a real discussion here. My bad.

Besides, I like the sun....

At the BLS level, you can only really observe and make crude inferences about what might actually be happening with your patient, especially with more subtle presentations and complex situations. "Oh oh, she's breathing 42 times a minute and her heart rate is 200. She needs to go to the hospital quickly and help controlling her breathing." At the ALS level, not only do you make observations, but you can take those and apply critical thinking to them because you have been given the educational toolbox to work with... and hence, you can initiate more treatments in the field and better communicate what you observe going on with the patient to the doctor once you arrive at the ER.

You see the same things and should be asking many of the same questions at both levels; it's what you do with the information and the other questions that you KNOW to ask at the ALS level that really delineates between an ALS and BLS assessment.

I hope this makes sense...

Wendy

CO EMT-B

I am not trying to be smart here. But, are you trying to insinuate that BLS providers are not taught critical thinking skills? Or, are you just stating that treatment modalities are different because of education levels?

Would you agree that the assessment part of it, step for step, is the same?

I don't have the capability to do a catheterization in the ER too, so maybe these patients should be treated by paramedics in the ER too untill they get to the cardiologist?

It's not about the skills one can perform or the drugs one can administer: here we're talking about the knowledge and level of education one should have when treating a patient in the field...

That is a dangerous assumption. I know some paramedics that have a lot more education and experience with body systems and A & P than most nurses in practice.

However, you are correct. This is not about skills or drugs. Although, I have been wrong before.

I think the point here is that Pre-hospital folks need to be accredited and licensed by their own governing body, as are nurses, PA's and physicians.

obviously someone doesn't comprehend sarcasm. I even posted 'sarcasm' after my reply.

I am not convinced

I think you misread EMT-1 as EMT-I. I think the issues is finding work as a basic basic not as an intermediate.

Dwayne

I just caught that. I guess I should follow my own advise....Attention to detail.

I would say that my last post still applies though. Although I have no actual knowledge of how the San Fransisco Hospitals work in regards to ER techs.

I know that at where I work, the ER techs are EMT-basics, and are taught 12-lead placement, and phlebotomy skills.

I guess that would be neat, if it applies.

HEY GUYS!!!1!!

Screw your fancy medicine, 15 LITER NRB AND GO GO GO!!

Practicing good medicine is for suckers. BLS > ALS!!! You guys suck!!!!11!

sarcasm off.

this whole thread makes me want to puke.

You Sir, need to get into a new line of work.

If that is the most intellegent reply that comes to mind.......FAIL!

It is basic issue like this, that effect OUR profession. Disappointing to say the least.

You may want to try your local Hospital or Urgency Care Facility, try to get a job as a Patient Transporter or any other entry level position; it'll give you an opportunity to get familiar with the hospital environment and equipment ( IV pumps, EKG monitors, respirators, etc...); you will also be making a lot of contacts and it looks good on your resume.

That's what I was going to recommend. But more like ER tech, EKG tech. That way you can use your EMT-I skills, and learn something in the process. That way, when you do turn 21, you will have more experience than some of your counterparts.

Of course, I don't know of how San Fran Hospitals run in regards to ER techs, etc.

First- thanks for the replies. This was my first thread on this site, so......

So, since we have been doing a little ALS vs BLS thing lately. I thought I would throw this out there. But....

Besides diagnostics, GO!

I think some of you missed this. I am really going back to basics here.

You should be assessing the same things either emt or medic level. But in your toolkit you have different items if you are an EMT and different items if you are a medic.

Comparison here

rapid heart rate > 200

you have on the medic side - 12 lead, cardiac monitor/defib/cardioversion

On the EMT side you have - pulse ox, bp/vitals, oxygen

Remember, it's not about YOU!~!!! it's about the patient.

Diagnostics!

Ruff is correct with his ahhh - assessment of the situation.

All I can add is even though the assessment criteria are the same, the advance perspective of assessment also incorporates a deep understanding of what is happening pathophyiologically with the assessment findings.

Think of it this way: Basic understand the body and systems. Intermediates (some) understand the body and systems down to the tissue levels. The Medics understand all this but down to the cellular level. All it is, is an understanding of what is going on based upon the assessment taken, which is the same.

This is only a wide observation in my opinion, and others may disagree and probably will.

That was more for what I was getting at.

Assessment should not change between BLS/ALS except 12 lead ECG

Education should be focused upon acquiring a comprehensive knowledgebase of A&P and patho at the entry-to-practice level so you can begin to consolidate that knowledge as soon as you hit the street

Remember, a 12-lead is a diagnostic. But I like where your head is at.

Ok, so AM571 I have to apologize to you. I had a feeling, likely unfairly, based on some of your earlier posts that you were going to turn out to be a butthead wannabe.

Posts like this, simple and smart yet that cut to the heart of many educational subjects in one conversation put the lie to my silly preconceive notions.

Thanks for taking the purpose of this site seriously.

Who's the butthead now? (it's ok, I'm used to it.)

Dwayne

It's OK Dwayne. I get that a lot. At times I can have a very abrasive personality. I spend half of my time in the military, and the other half in a civilian hospital on a Paramedic unit.

some people just don't know how to take me.....

I want to see if we can get any more replies, but I have a felling that most are in the same opinion as me.

Just one Caveat to the original post. Let me know how you voted when you post. Makes it easier.

thanks

J

So, since we have been doing a little ALS vs BLS thing lately. I thought I would throw this out there. But....

Besides diagnostics, what is (are) the differences between the ALS and BLS assessments, if any?

This might sound like a silly question. But I am kind of curious to see how peope view this. Especially after some of the more recent topics.

GO!

Then you're not taking appropriate BSI, FAIL!

LMFAO,ahahahahahahahahahahahahaaaaa...... .

This all may be true. But this screams Sexual Harrassment

Maybe a case where the ACLU would actually be useful......

OK, obviously a movie quote, but I don't recognize it, nor what it is supposed to mean. Movie/TV show? Translation?

It is from the Movie "Office Space"

An awesome movie about a guy with really crappy management.

"it's not that I am bad at my job. It's that I don't care."

Ruff----> Most of the ideas and thoughts posted on this thread were really good. But, I can simplify this with one word. COMMUNICATION!

It needs to be constant, and flow both ways.

Good luck. Oh also, Don't be a manager! Be a Leader!

The easiest way to increase morale is to find out what the staff don't like it and fix it. Make for them coming to work not "work" but some place the ENJOY coming to. The best jobs I've had are not because of the work but because of the people.

I had a job that was a really good JOB but the culture sucked it was just a bad place to work because the people were fucked in the head and it made the day long and hard.

Not sure what kind of system you are running, it would be hard to make them enjoy sitting on a street corner for ten hours but you could do something easy like throw a pool table in the lounge; internet; TV etc. If you have walls, tear them down (well not ALL of them) and get engaged with your people, show them you care, show them you're not a person to dole out punishment but somebody who cares about them as a person and not as bums on seats.

Things like paintball or orginised sports go down well, the social club here organises them and pays for cable TV at the station. Throw around a couple manakins and let them go nuts if they want to practice skills for example.

People who work TOGETHER with common VALUES and mutual RESPECT towards a SHARED GOAL will do more than any other, and that is a proven fact.

Thats it! Professional pride and Team cohesion. Work hard, play hard.....together.

You cannot possibly really believe that, can you?

He believes in hope and change Now back to reality.

I was referring to Primary, Advanced, and Intensive Care Paramedic but since you had to bring it up sure, Stanley my big grey pet elephant needs somebody to bring him peanuts and take him for a walk.

Also very true

Sorry, I couldn't help myself

So what titles do you suggest we use instead, I have mine above but what do you all think?

Elephant Keeper???????

I don't think it is the title that is the issue, but the manner in which we present ourselves.

This "holy'er than thou" or "I'm ALS (or BLS), therefore I am" attitude is what started this ..........ummm debate.

This sucks.

I used to fly Army medevac at Ft Bliss. The terrain there is different to say the least. But we worked the group from SW all the time on I-10. Definetly a good bunch.

There have been way to many Aeromedical crashes as of late.

WHY?

Thanks, long time lurker, first time poster....

At this stage, generally speaking, I would be in favour of removing lasix from the drug box, at least for the setting of suspected pulmonary edema - nitrates, CPAP and ACE Inhibitors are first line treatment for this, and irrespective of the difficulties with differentiating ACPE from pneumonia, it probably leads to worse outcomes. However, while there seems to be less and less of a role for it in the setting of ACPE, that is not to say that it does not have uses elswhere in pre-hospital care (hyperkalemia for example) although these instances may be rare, and a cost/benefit analysis should probably be undertaken.

I am, however, firmly against protocolisation (is that a word?) of emergency medicine as the sole form of clinical risk management. The first line of clinical risk management should always be education. In some cases further protocolisation may be required, but it shoud be a last resort.

Something else we need to be careful of is being against losing 'skills' or drugs for reasons other than patient care (ie. ego). There often seems to be an attitude that removal of a particular drug or procedure somehow reflects badly on us as paramedics (not that I am trying to imply that this is your stance; this is just a general observation) Now, if this has occured because, say we have been unable to differentiate between the decapitated/non-decapitated patient, then fair enough, we should be ashamed. However if it has occured because the best available evidence demonstrated no benefit, or even harm from using it, then we should happily wave it goodbye and maybe give it a Viking Burial at sea. We need to practice emergency medicine, not massive egotism.

The studies quoted earlier in the thread seem to me to relate to a systemic problem in the diagnosis and management of a particular cohort of patients in a particular service. One needs to be careful with making generalisations regarding our own practice or service from these kinds of studies without having read and understood the study in it's entirety, including any methodological errors before making decisions regarding it's applicability to our own specific circumstances. When we just read abstracts we end up with blanket statements being made like "RSI is bad, mmmmkay" that may not be appropriate depending on ones circumstances.

HHmmmm. I see your point, especially about reading abstracts.

However, I have a question in regards to ACPE. Would it be correct to state that diuretics have been used in the past (not necessarily by pre-hospital, but by MD's) to help reverse the shift of fluid in these cases? And if so, what is the potential benefit/risk in patients with well documented history of heart failure who are suffering from acute exacerbation?