ALS for the BLS Provider -- Assisting ALS

[Anjel]

When I first started in EMS, I hated the medics calling me their basic. I think I even argued with someone on here about it.

But now that I run in a busy 911 system, I see what my role is. I do everything in my power to help the medics. And to make their job a little easier. I am their best friend on scene.

I get the stretcher, bag, monitor, backboard, etc. I have them on the monitor, pulse ox, and BP cuff as soon as we walk in and I get the Glucometer ready.

In return they trust me, respect me, and teach me. They print me interesting strips so I can look and learn. Since I am a medic student they let me do other things.

We have a really good relationship. And each crew likes different things. It's all about learning what is expected, and getting it done.

I should say we run double medic double basic. A BLS and an ALS unit go on every 911.

 

[Handsome Robb]

I've never worked with a basic partner except when taking handoff reports from a special event crew or occasionally a ski patroller although usually we get reports from the ALS patrollers.

My partner does everything that's listed in this thread plus a little more but he's an Intermediate. He has his own, albeit small, list of IV/IM meds he can administer and attend the patient as well as assist me with things like code drugs and respiratory treatments "under direct supervision". With another little class and test while working alone or with a BLS partner at a special event their scope gets even larger after requesting an ALS intercept. There's a new-hire academy for equipment and procedure familiarization. The intermediates at the agency I work for are trained to assist in surgical crichs as well as bougie intubations. We run P/I with the occasional P/P truck mixed in. Every field employee goes through an annual skill re-certification as well.

The only thing I'm particular about that I always do myself is airway equipment. We do a required bag check at the beginning of every month that must be turned in to our logistics supervisor. My partner helps me with everything including the drug kit, except for my ALS airway kit. He knows not to go into it unless I directly ask him too. That's my only no-no that'll make me really mad except for endangering us or the patient and arguing with me on scene, otherwise I let my partner do a lot because he's asked me if he can do the majority of the skills, which is fine by me because he's proven himself to not be an idiot.

 

[Clare]

In Mass the state "ALS interface" guidelines don't even want basics setting up airway equipment prior to its use. OEMS provides a table of what is allowable and what is not, and those working with a medic are to be given an interface class, which I'll admit is probably not quite the norm.

So, the list you provided says an Emergency Medical Technician is not able to do any of the following things:

-- Insert LMA
-- Auscultate breath sounds for tube placement
-- Assemble capnography device or equipment
-- Retrieve or prepare drugs for administration
-- Apply tourniquet
-- Handle or dispose of needles
-- Cleanse the IV site
-- Operate or charge manual defibrillator

I don't mean to be rude, but I cannot for the life of me understand the rationale for such simple, basic, fundamental things not being allowed I mean, how on earth can this be?!

I mean maybe, maybe the only thing in that list that I would consider being unreasonable is preparation of drugs for administration by which I mean diluting drugs; if you're doing something simple like drawing 1 mg of adrenaline into a 1 ml syringe or something then that is different.

 

[Meursault]

I don't mean to be rude, but I cannot for the life of me understand the rationale for such simple, basic, fundamental things not being allowed I mean, how on earth can this be?!

You just have to remember to think like the protocol committee. Basics, not having sat through multiple state-sanctioned training courses on each subject, are to be presumed too dumb not to:

• Jam the LMA in unlubricated and upside down
• Misidentify air in the stomach as breath sounds (not a mistake unique to unskilled providers, and one of the more defensible entries here)
• Somehow assemble a capno sensor in such a way that it gives plausible but incorrect numbers
• Confuse clearly-labeled color-coded boxes and deceive the paramedic into doing the same. (Okay, not preparing meds seems like a sensible restriction)
• I can't for the life of me imagine how you can screw up a tourniquet. Moving on...
• Hurt themselves with pointy things,
• Lick the site clean.
• Fail to recognize numbers and/or press the wrong button.

And mind you, these are the basics who underwent a few hours of extra training on the subject. Presumably, basics who haven't been through the interface course are to stand very still and wait for the medics to explain what they need slowly and with small words.

Seriously, most of these entries, like breath sounds and capnography, are meant to ensure that a paramedic is responsible for every critical step of an intervention they perform. The alternative, educating and training EMTs to the point where they're somewhat trustworthy, is apparently unacceptable.

 

[Milla3P]

I don't mean to be rude, but I cannot for the life of me understand the rationale for such simple, basic, fundamental things not being allowed I mean, how on earth can this be?!.

Welcome to the US of A.

Would you expect anything different considering our national EMS standards are regulated by the Department of Transportation?

'Merica!

 

[Tigger]

In the eyes of the state, that isn't PB at all... there are two medics on the truck (somewhere), it would even be double medic if one medic was driving, with or without a basic in the back. As long as the expertise exists somewhere a time when the defecation hits the ventilation...
All of that does not mean proper PB training shouldn't be available, but its more often best provided OTJ by competent FTOs/Preceptors.

They do teach a course, but I am never around when they do it. It's the same with EVOC, but apparently I don't need that either.

I don't mean to be rude, but I cannot for the life of me understand the rationale for such simple, basic, fundamental things not being allowed I mean, how on earth can this be?!

I mean maybe, maybe the only thing in that list that I would consider being unreasonable is preparation of drugs for administration by which I mean diluting drugs; if you're doing something simple like drawing 1 mg of adrenaline into a 1 ml syringe or something then that is different.

You're preaching to the quire here. Massachusetts limits its EMTs significantly, for better or for worse. In the other state I work in (Colorado), things are much different. I can start IVs and things like that as an EMT, but under no circumstances would this be allowed in Massachusetts. Clear as mud?

 

[mycrofft]

Welcome to the US of A.

Would you expect anything different considering our national EMS standards are regulated by the Department of Transportation?

'Merica!

AH, someone's reading me!!!! Except I feel the too-loose NHTSA lets various EMSA's and States/Commonwealths dilute their EMT ratings with additional skills despite inadequate control or education, as a sop to employers.

 

[Brandon O]

Massachusetts limits its EMTs significantly

I chuckle when I hear people say this... you should see how bad it can get. BLS responsibilities in Mass (at least potentially -- I can't defend any specific service you may hang your hat at) are far greater than in many other areas.

 

[Trashtruck]

The closest I have ever come to committing murder was when my EMT B partner checked out the bus and found one of the laryngascope blades wasn't working. He deliberately didn't tell me about it because he figured he would just take care of it himself. He couldn't, and I only found out because he told the oncoming medic, who told me.

This is exactly why I check out my own gear, regardless if somebody said that they just checked it and 'it's fine'.
Not good enough in my book. I have to know it's good for myself for my own peace of mind.

As for when the EMT's assist, I let them do whatever they want, but I watch and if they screw something up(spiking a micro drip instead of a macro drip comes to mind), I don't yell or scold or demean them like I'm so awesome and have never done the same thing. I fix it, or they do, and explain after the call how to do X, Y, or Z. I like the extra set of hands.
If they really suck, I tell them to sit up front and I'll tell them when I'm ready to go.

 

[Trashtruck]

So, the list you provided says an Emergency Medical Technician is not able to do any of the following things:

-- Insert LMA
-- Auscultate breath sounds for tube placement
-- Assemble capnography device or equipment
-- Retrieve or prepare drugs for administration
-- Apply tourniquet
-- Handle or dispose of needles
-- Cleanse the IV site
-- Operate or charge manual defibrillator

I don't mean to be rude, but I cannot for the life of me understand the rationale for such simple, basic, fundamental things not being allowed I mean, how on earth can this be?!

I mean maybe, maybe the only thing in that list that I would consider being unreasonable is preparation of drugs for administration by which I mean diluting drugs; if you're doing something simple like drawing 1 mg of adrenaline into a 1 ml syringe or something then that is different.

And we wonder where 'ambulance driver' comes from...

 

[Christopher]

"Every patient requires BLS care, few patients require ALS care." This is what I tell EMT's who ride with me.

The biggest help to me is a competent EMT who can completely manage the BLS aspects of patient care while I add on any additional ALS care as necessary. In our area BLS providers have a broad scope, so this effectively means I'm only necessary to start a line and read a 12-Lead (maybe push a drug or two, ultimately I don't add much to the truck).

 

[Christopher]

You just have to remember to think like the protocol committee. Basics, not having sat through multiple state-sanctioned training courses on each subject, are to be presumed too dumb not to:

• Jam the LMA in unlubricated and upside down
• Misidentify air in the stomach as breath sounds (not a mistake unique to unskilled providers, and one of the more defensible entries here)
• Somehow assemble a capno sensor in such a way that it gives plausible but incorrect numbers
• Confuse clearly-labeled color-coded boxes and deceive the paramedic into doing the same. (Okay, not preparing meds seems like a sensible restriction)
• I can't for the life of me imagine how you can screw up a tourniquet. Moving on...
• Hurt themselves with pointy things,
• Lick the site clean.
• Fail to recognize numbers and/or press the wrong button.

And mind you, these are the basics who underwent a few hours of extra training on the subject. Presumably, basics who haven't been through the interface course are to stand very still and wait for the medics to explain what they need slowly and with small words.

Seriously, most of these entries, like breath sounds and capnography, are meant to ensure that a paramedic is responsible for every critical step of an intervention they perform. The alternative, educating and training EMTs to the point where they're somewhat trustworthy, is apparently unacceptable.

Our basics are entrusted with those skills...and I live in a state where Algebra is considered "advanced".

 

[Christopher]

I chuckle when I hear people say this... you should see how bad it can get. BLS responsibilities in Mass (at least potentially -- I can't defend any specific service you may hang your hat at) are far greater than in many other areas.

One of our volunteers was a MA EMT-B and NC OEMS made them take our State test due to the "lower educational standards" and "restricted scope" of MA.

 

[Brandon O]

One of our volunteers was a MA EMT-B and NC OEMS made them take our State test due to the "lower educational standards" and "restricted scope" of MA.

Yes, well. All things be relative, you lucky bastid.

 

[Christopher]

Yes, well. All things be relative, you lucky bastid.

They thought it was wicked ahhsome we could place KingLT's and nebulize albuterol.

 

[Milla3P]

One of our volunteers was a MA EMT-B and NC OEMS made them take our State test due to the "lower educational standards" and "restricted scope" of MA.

I'm sure it was the "lower educational standards" and "restricted scope"

I doubt OEMS wanted the testing and licensing fees.

 

[Christopher]

I'm sure it was the "lower educational standards" and "restricted scope"

I doubt OEMS wanted the testing and licensing fees.

No cost to test or get your certification (outside of any classes or background checks) in NC. I don't pay to recertify.

 

[VFlutter]

"Every patient requires BLS care, few patients require ALS care." This is what I tell EMT's who ride with me.

I totally agree with that statement however IMO every patient deserves an ALS assessment. (Outside the obvious like "I need to get to the ER for a script refill)

 

[EpiEMS]

I totally agree with that statement however IMO every patient deserves an ALS assessment. (Outside the obvious like "I need to get to the ER for a script refill)

To be fair, anybody with ALS-level education can do an ALS assessment. You're a BSN, you can certainly do a medic-level assessment, even if your EMT cert says you can't do ALS treatment.

Assessment isn't something that scope of practice limits, other than perhaps the tools you are allowed to use.

 

[Brandon O]

To be fair, anybody with ALS-level education can do an ALS assessment. You're a BSN, you can certainly do a medic-level assessment, even if your EMT cert says you can't do ALS treatment.

Assessment isn't something that scope of practice limits, other than perhaps the tools you are allowed to use.

This, a thousand times. Any non-invasive assessment and diagnostic techniques that use nothing more than BLS equipment (i.e. H&P) are open game. Granted, if you make a ridiculous treatment decision based on your misunderstanding of Cullen's sign, you're probably on your own, but ridiculous decisions are always off the reservation.

To me, an "ALS assessment" includes diagnostic devices only a medic carries and is trained to use, such as the ECG. When people use it to mean "a competent assessment," I understand what they mean, but I find it vexing.