Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

ALS is Oxygen, IV, Monitor, and Transport

In response to a question about a complicated ECG strip, someone responded that Oxygen, IV, Monitor, and Transport are all that is needed. Perhaps this was meant sarcastically. Perhaps not.

I do know people in EMS who think this way.

I also know people who think about people in EMS this way.

If Oxygen, IV, Monitor, and Transport define ALS in EMS, we are in trouble.

Why isn’t this blood pressure, along with the rest of the vital signs, enough?

I rarely give oxygen.

We should be giving drugs only for a specific effect.

We should not be giving drugs just to satisfy a protocol.

We should not be giving drugs to satisfy a mnemonic.

A mnemonic is a memory aid.

A mnemonic is not a standing order.

How often do we give anything other than a flush through an IV, or a saline lock?

If we are only using it to make the mnemonics Nazis happy, are we helping our patients?

Does an asthmatic need an IV to receive a bronchodilator?

What about getting an ECG for every ALS patient?

Let’s consider that the origin of this post was a comment that medics do not need to be able to interpret complex rhythms, because we just do Oxygen, IV, Monitor, and Transport.

If the medic cannot figure out what the rhythm is, why hook the patient up to the monitor? Satisfying billing? Satisfying QA/QI/CYA gnomes? Something else?

Should we transport every ALS patient?

What if this conflicts with informed consent?

What if we insist that patients agree to transport in order to receive treatment?

What about ALS treatment requires transport?

In other words, Oxygen, IV, Monitor, and Transport are not essential to ALS in EMS.

Is a doctor required to give oxygen for treatment to be ALS?

Is a doctor required to have an IV for treatment to be ALS?

Is a doctor required to have an ECG for treatment to be ALS?

Maybe we need to allow medics to think.

Maybe we need to encourage medics to think.

Maybe we need to require medics to think.

.

Comments

  1. wow. this sounds about right, but it shouldn’t be.

  2. You bring up some good points. I think a lot of it unfortunately rests with comfort and education. They run hand in hand. The region and state don’t always trust the medics to think and the patient’s suffer for it. It’s hard for me to be a cook book medic when I know that the patient needs or does not need a treatment. Our protocols treat all chest pain calls as cardiac instructing us to give aspirin and nitro regardless of other factors. They are too afraid to allow medics to make a differential diagnosis of chest pain from a non cardiac sources. We have spent a lot of time working with the medical control physicians to build trust and be able to provide the care a patient needs, not the care the system feels will avoid lawsuits. I look forward to the day when we are truly an extension of the ER physician’s care as we are supposed to be now.

    • Scaredy Fish,

      You bring up some good points. I think a lot of it unfortunately rests with comfort and education. They run hand in hand.

      Too many of us in EMS are trained to not think.

      This is not education, but indoctrination.

      The region and state don’t always trust the medics to think and the patient’s suffer for it. It’s hard for me to be a cook book medic when I know that the patient needs or does not need a treatment.

      I suppose I need to make a confession.

      I am a complete failure as a cookbook medic.

      I have been fortunate to have plenty of medical directors who have encouraged me to treat the patient, rather than treat the protocol.

      Our protocols treat all chest pain calls as cardiac instructing us to give aspirin and nitro regardless of other factors. They are too afraid to allow medics to make a differential diagnosis of chest pain from a non cardiac sources.

      While I am opposed to having medics encourage chest pain patients to refuse transport, there is no reason to insist that we treat every patient who could possibly be put into a chest pain protocol with all of our Chest Pain treatments. I have an ACS (Acute Coronary Syndrome) protocol, not a Chest Pain protocol.

      We have spent a lot of time working with the medical control physicians to build trust and be able to provide the care a patient needs, not the care the system feels will avoid lawsuits. I look forward to the day when we are truly an extension of the ER physician’s care as we are supposed to be now.

      EMS that forbids thinking cannot be EMS.

      EMS requires thinking EMTs and thinking medics and thinking nurses and thinking doctors.

      If we prevent any of them from thinking, we harm patients.

      .

  3. there is, alas, currently no penalty for not thinking… That may explain the status quo.
    Eff Dogg.

  4. Some services want the medics to follow the protocol and hound them for not following it to the letter. The good services want there medics to think and if they don’t follow protocol yes they are asked about it if not clearly defined in the report and when given the differential diagnosis they tell them good job. If you work for a cook book service then either you spend a lot of time in the office but your patients are better for it or you conform. I will not conform to a protocol for every patient I will always look at what the patient needs. Now sometimes if you do too much for the patient and “fix” them before they get to the ED and the ED doctor does not treat them correctly because they don’t trust what you say and how the patient was to begin with. I have had that happen a few times and had the patient worse when they were discharged from the ED and have to call again.

    • MOE Medic,

      Some services want the medics to follow the protocol and hound them for not following it to the letter.

      Those services are good for irresponsible and unethical people – not the kind of people we should allow to treat patients.

      The good services want there medics to think and if they don’t follow protocol yes they are asked about it if not clearly defined in the report and when given the differential diagnosis they tell them good job.

      There is nothing wrong with having to explain why I deviated from protocol.

      There is something wrong with not being able to explain why I deviated from protocol. There is even more wrong with forbidding medics from deviating from protocol.

      If you work for a cook book service then either you spend a lot of time in the office but your patients are better for it or you conform.

      I have never been good at conformity.

      There are some limited benefits from conformity.

      Conformity is about choosing to fit in vs. choosing what is best for the patient.

      I will not conform to a protocol for every patient

      A protocol can never cover all of the possibilities, so there must always be room for deviation.

      There should always be the expectation that deviations are appropriate until proven otherwise.

      I will always look at what the patient needs.

      It is obscene that some protocols are enforced with the expectation that we should not do what is best for the patient, but do what is best for an incompetently written protocol.

      Now sometimes if you do too much for the patient and “fix” them before they get to the ED and the ED doctor does not treat them correctly because they don’t trust what you say and how the patient was to begin with.

      One of the advantages of the newer monitors is the ability to record much more information. When we were able to provide NIBP Non-Invasive Blood Pressure machine) evidence of hypotension, it was much easier to convince doctors and nurses that the patient really was hypotensive. Another possibility is to record video of anything unusual and make sure that it only goes to the appropriate people. The same people who insist on absolute protocols will oppose this, because it means trusting EMS to make decisions.

      I have had that happen a few times and had the patient worse when they were discharged from the ED and have to call again.

      This will happen sometimes, but we are limited in what we can do to convince the doctors and nurses that the patient presented very differently earlier.

      .

  5. Quite a few of the problems I see in the local ED come from the ED doc “practicing medicine”. Hey, I’m a doctor! Let’s just drop ten of Versed on this patient and try to intubate, instead of following my well established RSI protocol developed by ACEP. Or, hey, I’m a doctor! Let’s shock sinus tach at 140 instead of giving fluids and pain meds for that fractured femur! We “require” ED docs to think, “requiring” medics to think won’t fix the legal system or increase our knowledge base or skill level.

    I agree with a lot of what I read here. However, why is anyone going to give a medic with 18 months of technical school freedoms that ED docs with 8 years of medical education can’t always handle?

    Unless you work for a service that practices “different rules for different medics”, you’re going to have to stay within protocol – not necessarily throw the protocols at every patient, but at least remain within them, or know enough to convince a reasonable doctor to agree with you. I’m willing to give up some freedoms that I might be able to handle so they won’t be abused by a lazier or less proficient medic, and call med control. It’s all about doing the greatest amount of good for the largest amount of people, not stroking our ego by allowing us to declare C/P non-cardiac or do sutures.

    Am I happy about that – no, but I didn’t go to medical school or do an internship either.

    • Amen, my brother. I have no doubt the blogger has the education, experience, and reasoning ability to appropriately treat his or her patients (sorry Rogue, I know thee not). Unfortunately, Rogue is an anomaly, not just in EMS, but in society. The vast, unwashed masses out there are just not that damn bright. The really, really smart people go into professions where they can actually make a living unless they are adrenaline junkies or just lacked the opportunity to go somewhere else. Paramedicine is heading in the right direction with national standards and accredited training programs, but there is a long road ahead before we weed the cookbook medics (and worse) out of the system. Do you REALLY want the guy who doesn’t know that naloxone is generic for Narcan making treatment decisions for your loved ones?

      I can rattle off “IV, O2, monitor” with the best of them in training situations, but I make my own call on the necessity of those items when treating patients.

      Does every patient need an IV? No, but THEY called 911, not me. If it’s not an emergency and you don’t want an IV, call a cab. I consider it to be part of maintaining my skill level so that when I get a patient who REALLY needs an IV, it’s no sweat. Especially peds. If you call me because your kid has a temp of 99.8, they’re getting an IV for hydration. I have found pediatric IVs are MUCH more traumatic on the parents than they are on the kids.

      With all the new studies out about free radicals, I titrate O2 to 99% sat. If that’s room air, so be it.

    • Prmedc,

      My reply is at Comment on ALS is Oxygen, IV, Monitor, and Transport – Part I. Later in the week will be Part II (not posted, yet).

  6. Sadly, I recently worked for one of these cookbook services. Currently, they are reviewing calls that paramedics turn over to BLS or do not use a monitor on. They require the medics to write a seperate incident form detailing why a monitor was not used. First of all, this assumes that dispatch, while not necessarily their fault, dispatches ALS to only ALS patients. Secondly, with the justification report, it’s just easier to put the monitor, get my six second 3 lead strip (which does nothing but diagnostically for a patient I’ve determined has a stable pulse rate). The case I was going back and forth with the QA guy over was a patient another ALS crew had already evaluated, gotten a six second strip, and determined to be BLS. They sent us as a medic unit to transport because the first unit had a mechanical failure. The QA guy still wanted my ECG. WHY DID HE NEED ME TO REPEAT WHAT ANOTHER MEDIC FROM MY SERVICE DID???? Sorry to yell, but it was frustrating going back and forth with him over an unnecessary procedure that was laready performed, and he never saw my point that it was already done.
    Sadly, we are discouraged from thinking in many areas, especially when the hire ups are discouraged from thinking.

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