pesonnaly i believe that every nurse should hold such a certification regardless the where is the place of working.
cheers,
"ry"
On 12/10/05, yudhis97 <[EMAIL PROTECTED]> wrote:
BTLS vs. PHTLS
I have already made my feelings on "merit badge medicine" known
[see "We Don't Need No Stinkin' Badges!"]. These courses are OK for
continuing education—but should never be required as a condition of
employment or certification. However, I would like to turn our
attention to the phenomena of Basic Trauma Life Support (BTLS) and
Prehospital Trauma Life Support (PHTLS). These two courses are among
the most popular "merit badge" courses in EMS. But there seems to be
some redundancy between the two, and wherever there is redundancy,
there is increased cost.
The history, as I remember it, was that BTLS was developed by John
Emory Campbell, MD, and the Alabama Chapter of the American College
of Emergency Physicians (ACEP). The book, now in its 5th edition,
bears a 25th Anniversary Edition label and has been continuously
published by Brady. BTLS has an international organization and a
board of directors, comprising primarily physicians, of which Dr.
Campbell remains the president.
The history of PHTLS is somewhat similar. In 1981, the National
Association of Emergency Medical Technicians (NAEMT) asked Norman
McSwain Jr., MD, to develop an "ATLS course for non-physicians" that
would be loosely based on the American College of Surgeons Advanced
Trauma Life Support (ATLS) course. A committee was appointed, and the
first courses were conducted in 1983. The textbook, originally
published by Emergency Training International (ETI) and later by
Mosby, is also in its 5th edition. PHTLS remains under the aegis of
the NAEMT, and Dr. McSwain remains its medical director. (Publisher's
note: Mosby and Jems are both imprints of Elsevier Inc.)
Although most states accept either certification, considerable
allegiance and loyalty to each course is evident among providers. I
have some friends who swear by BTLS while others prefer PHTLS. I
actually saw a fairly heated argument in a tavern in Phoenix many
years ago about whether the BTLS term "Kinetics of Trauma" was right
or whether the PHTLS term "Kinematics of Trauma" was correct. Both
men had admittedly had too much to drink, but the argument was
interesting. The two organizations seem as juxtaposed to each other
as you would see in any political party. The information provided by
the courses has typically been similar. So why two courses? Why two
textbooks? Why two organizations? Why two sets of instructor manuals?
Why two sets of PowerPoint slides? Why can't there be just one course?
I understand that this is a capitalistic society and competition is
good. I understand that PHTLS is a major source of income for the
NAEMT and BTLS is a source of income for Alabama ACEP. Both
publishers must be making money from the textbooks, or they wouldn't
continue to revise and publish them.
But here is the problem. As these courses have independently evolved,
they have taken slightly different directions. Because of this,
treatments have started to vary. Also, these courses have not
adequately reacted to changes in the medical literature. This
divergence is now becoming a problem for students. I recently had a
young paramedic ask about the appropriate target blood pressure for
trauma patients. BTLS says the systolic pressure should be between 90
and 100 mmHg, but PHTLS says it should be between 80 and 90 mmHg.
Although I think PHTLS is more correct, that doesn't help the
student, especially when they take a re-certification exam in their
state. EMTs and paramedics, especially those new to the profession,
need to know the standards and they will then strive to achieve them.
If they are unsure of the standards, they are then unsure in their
care.
Other problems exist in these courses. Extensive material on MAST
remains despite the fact that the preponderance of the medical
literature says these are nothing but an inflatable splint and play
no role in shock management. Another example is the algorithms for
spinal immobilization. PHTLS primarily follows the NEXUS criteria and
BTLS follows the Maine Protocol. Both are accurate—but are different
in their process. Again, this causes confusion in our industry.
Although I'll be declared a heretic (again), I think it's time we
have the two entities sit down and do one of two things: Combine the
courses and the organizations. (Reduction of this redundancy will
save money and allow the course to be offered to more people at a
lesser cost.) Or have a consensus conference with each publisher and
their experts represented to ensure that both programs are conveying
the same information to EMS students.
I would like to see everything become evidence-based, as we are
seeing with the American Heart Association and the Brain Trauma
Foundation. Each organization should then suggest standards,
guidelines or treatment options on the basis of the level of
scientific evidence supporting each.
I know it will be difficult to accomplish because money and tradition
(and name badges) are involved. But it would be better for EMS and,
ultimately, better for patient care.
Bryan E. Bledsoe, DO, FACEP, is an emergency physician in Texas. He
can be contacted at [EMAIL PROTECTED].
Disadur dari http://jems.com
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