BLS Skills -- What Should We Add?

[JMorin95]

Become a higher license level if you want more skills.

 

[Clare]

Become a higher license level if you want more skills.

For last several years we've been getting new skills/medicines for each level each time clinical procedures are updated.

EMT (BLS) has gotten 12 lead ECG acquisition (although they have always been able to do this it is now just formally added), PEEP, tourniquets, adrenaline, ipratropium, ondansetron, and loratadine

Paramedic (ILS) has gotten ceftriaxone, fentanyl and midazolam

Intensive Care Paramedic (ALS) has gotten vecuronium, adenosine, ketamine, and had frusemide withdrawn

There will always be change in what somebody can do so you don't necessarily need to move up to next level and many things that were once "advanced" e.g. morphine or adrenaline are now not considered so.

 

[RocketMedic]

I am greatly confused

We learn in year one at uni how to acquire a 12 lead ECG; so long as you understand the basic electrophysiology of the leads (I forget the name of it, but it is some triangle...) coupled a simple anatomy of the thoracic cage it's pretty hard to stuff up putting on sticky dots and making sure its not full of artifact etc.

It's even taught to the vollies on nat dip

I also don't get why you transmit the ECG? The only time that that is done here is for cardiologist review for thrombolysis; surely nobody who is not ICP is thrombolysing so I don't get it ...

Am I just not getting something here that is screamingly obvious?

We transmit our ecgs to the hospital to activate our cath labs and for consults on "odd" ecgs, and in my system, for most antiarrythmics. I like having the option.

 

[Clare]

We transmit our ecgs to the hospital to activate our cath labs and for consults on "odd" ecgs, and in my system, for most antiarrythmics. I like having the option.

I have been amazed by how many hospitals in NZ cannot do PCI; there are only nine that can, three of which are in Auckland (ACH, MMH and NSH) as well as Hamilton, Tauranga, Wellington, Nelson, Christchurch and Dunedin.

This leaves a massive proportion of the population spread across vast geography only able to access thrombolysis and then they must be transferred by road or air several hours away for angioplasty and/or stenting.

In a way I am actually somewhat ashamed to have found this out.

 

[nolimits]

What additional skills does every patient deserve? What does the EMT, as a provider of competent medical care, need to be able to provide, beyond the BLS basics?

As far as BLS basics, I'm referring to assessment and treatment modalities such as C-spine stabilization, auscultating blood pressure, splinting, CPR and AED, and basic airways.

I think that, at this juncture, there is enough evidence and/or experience (where applicable) - not to mention plenty good rationale - to add the following skills to the EMT level (at the national and state levels):

- Glucometry
- 3- and 12-lead placement and transmission
- Blind insertion airway devices
- SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
- Sublingual nitroglycerin (carried on ambulance -- not just prescribed)
- Rectal diazepam (carried on ambulance -- not just prescribed)
- MDI or Nebulized Beta agonists (carried on ambulance -- not just prescribed)
- IN naloxone

Any of these make sense to anyone else? Glad to explain my rationale and provide evidence for any of these.

Diazepam and Naloxone is in the EMT-P scope of practice, not EMT-A. Although, wouldn't it be nice to piss off a chronic heroin user?

 

[Clare]

Diazepam and Naloxone is in the EMT-P scope of practice, not EMT-A. Although, wouldn't it be nice to piss off a chronic heroin user?

No it wouldn't; that is very mean, and unprofessional thing to say.

I don't see a role for midazolam or naloxone at the BLS level; anybody can administer a patients own pre-prescribed midazolam (the vast majority of patients who have known epilepsy have this) and naloxone is so rarely used its not even funny.

Why transmission of ECG?

 

[nolimits]

No it wouldn't; that is very mean, and unprofessional thing to say.

I don't see a role for midazolam or naloxone at the BLS level; anybody can administer a patients own pre-prescribed midazolam (the vast majority of patients who have known epilepsy have this) and naloxone is so rarely used its not even funny.

Why transmission of ECG?

So letting them destroy themselves would be the alternative?

 

[nolimits]

No it wouldn't; that is very mean, and unprofessional thing to say.

I don't see a role for midazolam or naloxone at the BLS level; anybody can administer a patients own pre-prescribed midazolam (the vast majority of patients who have known epilepsy have this) and naloxone is so rarely used its not even funny.

Why transmission of ECG?

I'm not sure of what neck of the woods your from, but Narcan is pretty popular around here.

 

[Wheel]

So letting them destroy themselves would be the alternative?

Are you of the opinion that slamming them with narcan will help their addiction problem? Somehow I doubt rapidly removing their buzz is going to make them never want to do heroine again.

I don't agree with that lifestyle, but causing pain for pains sake isn't good medicine.

 

[CPRinProgress]

What additional skills does every patient deserve? What does the EMT, as a provider of competent medical care, need to be able to provide, beyond the BLS basics?

As far as BLS basics, I'm referring to assessment and treatment modalities such as C-spine stabilization, auscultating blood pressure, splinting, CPR and AED, and basic airways.

I think that, at this juncture, there is enough evidence and/or experience (where applicable) - not to mention plenty good rationale - to add the following skills to the EMT level (at the national and state levels):

- Glucometry
- 3- and 12-lead placement and transmission
- Blind insertion airway devices
- SQ Epinephrine, i.e. EpiPens (carried on ambulance -- not just prescribed)
- Sublingual nitroglycerin (carried on ambulance -- not just prescribed)
- Rectal diazepam (carried on ambulance -- not just prescribed)
- MDI or Nebulized Beta agonists (carried on ambulance -- not just prescribed)
- IN naloxone

Any of these make sense to anyone else? Glad to explain my rationale and provide evidence for any of these.

In NJ EMTs need a separate cert to administer an unprescribed epipen. This is how some of these skills should be treated. Valium and narcan I don't see a reason for they need in depth skills to administer and for me at least, medics are usually on scene within 5 minutes of bls so for us those wouldn't change much pt outcome. As for the rest, there should be classes you must take to be able to do these on a pt. Even setting up an iv for medics could be good

 

[Tigger]

Diazepam and Naloxone is in the EMT-P scope of practice, not EMT-A. Although, wouldn't it be nice to piss off a chronic heroin user?

Nalaxone is the basic scope of practice in the two states I work in. In Massachusetts basics can give it IN and in Colorado it's either IV or IN.

Whether we have the proper baseline education to be doing this is up for debate however...

 

[EpiEMS]

I don't see a role for midazolam or naloxone at the BLS level; anybody can administer a patients own pre-prescribed midazolam (the vast majority of patients who have known epilepsy have this) and naloxone is so rarely used its not even funny.

Why transmission of ECG?

One of the many problems with EMS in the US is that we don't have consistent national protocols. Then again, it's an advantage in the "laboratories of EMS" sense. Naloxone has been used by non-trained folks in several areas without adverse consequences, if I remember correctly. I understand that it's got problems, but I'd rather have a spontaneously breathing patient than one that needs to be bagged.

Transmission for EMTs without the training to read and interpret for those services that have EMTs or AEMTs as their highest level of training (or no full-time medic coverage) such that the ED doc or cardiologist can, say, activate the cath lab, or whatnot. If you've got the LifePack in the rig, it's worth using it.

 

[JPINFV]

So letting them destroy themselves would be the alternative?

Because it's your place to punish them?

 

[nolimits]

In NJ EMTs need a separate cert to administer an unprescribed epipen. This is how some of these skills should be treated. Valium and narcan I don't see a reason for they need in depth skills to administer and for me at least, medics are usually on scene within 5 minutes of bls so for us those wouldn't change much pt outcome. As for the rest, there should be classes you must take to be able to do these on a pt. Even setting up an iv for medics could be good

Because it's your place to punish them?

No, but when they cannot follow commands, or maintain an airway, it becomes a tiny issue. No?

 

[JPINFV]

No, but when they cannot follow commands, or maintain an airway, it becomes a tiny issue. No?

Follow commands? As long as they're just laying there I see no problem.

Maintaining an airway is a problem, but that's fixed with a titrated dose that shouldn't bring about bad juju.

 

[Medic Tim]

Diazepam and Naloxone is in the EMT-P scope of practice, not EMT-A. Although, wouldn't it be nice to piss off a chronic heroin user?

The EMT scope in AB is not as large some other provinces. I have given diazepam and narcan back when I was a PCP ((EMT)Within scope and protocols) . Narcan is still a BLS skill in some areas.

I hope you were trying to be funny for that last part

 

[Wheel]

Follow commands? As long as they're just laying there I see no problem.

Maintaining an airway is a problem, but that's fixed with a titrated dose that shouldn't bring about bad juju.

This. The last thing I want is a combative patient. If they can't maintain their airway or they aren't sufficiently ventilating, then they get enough narcan to help them out, not wake them up.

 

[DesertMedic66]

Follow commands? As long as they're just laying there I see no problem.

Maintaining an airway is a problem, but that's fixed with a titrated dose that shouldn't bring about bad juju.

I love it when I work with medics who do this. Sadly we have some medics who still "slam" the narcan. Fire will normally ask for the meds and then slam them and hand patient care over to us :glare:

 

[STXmedic]

Meh, we typically treat and release heroine ODs. Still don't slam it though, and ventilate 'em before waking them up.

 

[VFlutter]

Diazepam and Naloxone is in the EMT-P scope of practice, not EMT-A. Although, wouldn't it be nice to piss off a chronic heroin user?

Ya since every patient who needs Narcan is a chronic heroin user. Ever see a cancer patient who took too much narcotics, not to get high, but just trying to take away the legitimate pain they are suffering from? Wouldn't it be nice to not have to intubate them...