Jeramedic posted a blog called ALS Kills People. It’s a good read, click here, then come back (my rant will make more sense I promise).
I complained recently about how EMS medical directors and services are looking to reduce the ALS interventions that paramedics can perform. I understand the initial intent to reduce the patient mortality and injury and increase survivability. Before anyone pulls interventions from our tool box, we need established scientific studies to prove if the interventions work or do not work. Let’s not just have knee jerk reactions across the industry.
When was the last time you intubated a patient in the field? When was that last time you performed a thoracentesis? I have not worked a full arrest since getting my paramedic license over a year ago. I have only worked two full arrests during my ride time, performing oral intubation once. I have not orally intubated a patient since ride time. Should I remove intubation from my possible treatments? Should I no longer “run” a full arrest?
Jeramedic put forth that we need to view our interventions (both ALS & BLS) like the fire service views special rescue teams, and police view SWAT teams. During my employment as a firefighter I was on all of the special rescue teams, and we trained four hours every quarter at a minimum, Water Rescue, Trench Rescue, Rope Rescue, Confined Space Rescue and Ice Rescue all had their place on our training calendar. Hazmat was one area my fire chief thought we needed to be more proficient than the average fire department. We trained on hazmat once a month. Firefighting skills were drilled once a month, sometimes once a week. I was a big advocate of training every shift, given the long list of specialties that we needed to maintain (including BLS care).
Why on earth do we in EMS think that 48 hours every two years is adequate to maintain our skills? The interventions we use infrequently but could be considered life saving need to be second nature to us when we need to perform them. I stole the risk matrix from Gordon Gram when I taught my fire fighters. There were four categories in the matrix, High Risk/Low Frequency, High Risk/High Frequency, Low Risk/Low Frequency, Low Risk/High Frequency. We can use this matrix in a similar manor applied to medical interventions. Risk will be applied as risk to the patient, and frequency will be the number of times over a given date range.
Low Risk/High Frequency Interventions:
- Nasal Cannula
- Blood Glucose
Low Risk/Low Frequency
- Oral Glucose
- Splinting & swathing
High Risk/High Frequency
- Intravenous Catheter
- Nebulizer Medication Administration
High Risk/Low Frequency
- Oral endotracheal Intubation
- External Cardiac Pacing
- Nasal endotracheal Intubation
- Intraosseous placement
- Needle Cric
- Therapeutic Hypothermia
- IV/IO medication administration
The lists above are not all inclusive and are based on interventions that I perform in the field. Your list might look different, and I encourage you to identify the high risk/low frequency interventions.
Many of our ALS interventions can be classified at high risk/low frequency. This is the area we need to concentrate on perfecting if we want to maintain the interventions. As a prehospital provider, we need to be training on the interventions that we do not perform often to reduce the risk to the patient. Minimum guidelines are just that, we should exceed the minimum standards in our attempt to become better providers of prehospital care.
I do not want to minimize the importance of didactic education, only take a small look at emphasizing the need for improvement in psychomotor skills. We should focus the skills sessions on the high risk/low frequency interventions, and we should train a few minutes every shift on these skills. Pick one skill in the HR/LF category and spend a few minutes every shift on proper procedure, technique and protocols. You want to advance our profession from a trade to a medical profession, then we need to be able to demonstrate excellence in what we do everytime.