BLS Skills -- What Should We Add?

[usalsfyre]

Although, wouldn't it be nice to piss off a chronic heroin user?

This is exactly why most EMTs (and a hell of a lot of medics) have no business with naloxene.

 

[DrParasite]

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

wait what? in almost 15 years in NJ EMS, I can say you do not ned a seperate cert to administer an unpresribed epipen. you need to take a short class at your agency (since I wasn't in most people's original class), but the records are all kept internally, and the state doesn't track who does and who doesn't take it.

I would love to live nasal narcan. not killing a high for fun, but to wake up an OD slowly to assist in maintaining their own airway. And contray to your statement, ALS isn't only 5 minutes away, sometimes they aren't available at all.

and I can set up an IV for the medic.... I can't start one, but I can have it ready to go once they ask for it... don't need a seperate cert for that either....

 

[KingCountyMedic]

Here in Washington State you can get narcan when you exchange your dirty needles for clean ones at many places.

 

[ExpatMedic0]

Here in Washington State you can get narcan when you exchange your dirty needles for clean ones at many places.

Ya, I know of a case where the users friends (who where also high on heroin) successfully used narcan they obtained to bring back in OD in their apartment.

 

[Tigger]

Ya, I know of a case where the users friends (who where also high on heroin) successfully used narcan they obtained to bring back in OD in their apartment.

There are many success stories from a similar program run by the Massachusetts Department of Health. The state also provides nasal nalaxone to police officers (first responder trained) in areas of high use.

 

[Av8or007]

What the USA really needs is increased paramedic education at the basic level. In canada, our BASIC primary care paramedics have a two year college diploma, and the advanced care medics have 1-2 years more. Critical care paramedic is a year and a bit on top of ACP.

http://en.wikipedia.org/wiki/Paramedics_in_Canada

In ontario, most services allow PCP's to initiate IV therapy, insert SGA's (the king-lt), use CPAP .etc. Ontario PCP's will soon be able to perform manual defibrillation.

In canada, first responders are a tad under an EMT-B, and do NOT require full medical direction to use airway adjuncts AMFR skills off duty.

The best solution for canada and the US would be to bring up ALL medics to the PCP/ACP level, them make the FIRST RESPONDERS an EMT-B level with some extremely basic drugs such as epi-pen, asa and salbutamol (NO NITRO!).

 

[Medic Tim]

What the USA really needs is increased paramedic education at the basic level. In canada, our BASIC primary care paramedics have a two year college diploma, and the advanced care medics have 1-2 years more. Critical care paramedic is a year and a bit on top of ACP.

http://en.wikipedia.org/wiki/Paramedics_in_Canada

In ontario, most services allow PCP's to initiate IV therapy, insert SGA's (the king-lt), use CPAP .etc. Ontario PCP's will soon be able to perform manual defibrillation.

In canada, first responders are a tad under an EMT-B, and do NOT require full medical direction to use airway adjuncts AMFR skills off duty.

The best solution for canada and the US would be to bring up ALL medics to the PCP/ACP level, them make the FIRST RESPONDERS an EMT-B level with some extremely basic drugs such as epi-pen, asa and salbutamol (NO NITRO!).

Why no nitro?

 

[Av8or007]

Nitro assist is definitely ok, but we shouldn't carry nitro. As a amfr 1 with additional training and knowledge, i am fully in support of us not carrying nitro due to the risks.

Under the Ontario protocols for nitro, a 12 lead is required to rule out rvi. This makes sense due to the harm that can result if nitro is given to a patient with right sided MI. Nitro assist ensures that the pt has a hx of nitro use. Now, just because you don't carry nitro would not mean that you would not be required to know and understand it's pharmacology - knowing when a protocol/guideline doesn't apply is just as, if not more than knowing when it does.

If you are talking paramedics, at any level then they do and should carry nitro.
Same would go for any fr service which trained the providers in ecg interp and 12 leads - ecg interp is not a regulated act, not taught as part of the amfr scope of practice, but it doesn't make it illegal for an mfr who has received the appropriate training/education to interpret an ecg.

 

[Trashtruck]

I still can't really understand how such a limited amount of training seems to be allowed in the US. the country that seems to like being known as the best in everything?

If you want to be a two bit volunteer out on some rural station here you have to complete the Diploma which takes at least 400 hours of learning and if you want to actually get paid for it and do complex stuff then it's a three year degree minimum.

Mind you I have never met nor worked with Americans so I can't say but somebody on here said something like a 150 hour course and you can't even check a blood sugar? crazy!

It's truly disgusting in some parts of the US. The EMT-B's where I work cannot even take a blood pressure accurately. They look at the needle and make it up. Don't even mention lungs sounds to them, or how to place an appropriately size cervical collar on somebody. They do not have pulse oximeters or glucometers, nor do they carry any drugs(other than O2, which they don't know how to use since 15lpm NRBM for EVERYBODY is an undisputed practice. Oh, and oral glucose, which is placed down unconscious people's throats more times than I can count). No IV. No EKG. The doctors in the ED roll their eyes and I quote, 'They're absolutely worthless'
They don't say this because of the lack of skills that they are able to do. They say this because they are so poorly educated that they have awful assessment skills and cannot even tell if somebody is dead or not. Seriously. Codes come in unbeknownst to the crew bringing them in. 'They were breathing when we got there...'
I have no words for that...

I believe EMT-B's should be trained AND EDUCATED(not just be able to read a number off the screen and report it) to use pulse oximeters and glucometers. They should be able to start IV's and perform 12-lead EKG's(not interpret). Supraglottic airways should be in their scope as well as CPAP. Drugs should include D50, Narcan, B2 agonists, ASA, and IM Epi for anaphylaxis.
This is light years upon eons upon light speed and time travel physics away for here...

I envy the systems I read about where the EMT's do all this stuff. Sounds good.

Oh, and on the narcan bit. Clare, I remember you saying(I think) that you guys don't have a huge opiate addiction population down there. In the US, and certainly in certain areas, it's very, very common. We carry boatloads of narcan because we use it so much.
And to nolimits, once you wake up a junky by slamming narcan and he tears you up, you'll never do it again.
Opiate OD's usually get up and walk away. If you do transport them to the ED, they are sent to the waiting room, where they walk out.

 

[Medic Tim]

Nitro assist is definitely ok, but we shouldn't carry nitro. As a amfr 1 with additional training and knowledge, i am fully in support of us not carrying nitro due to the risks.

Under the Ontario protocols for nitro, a 12 lead is required to rule out rvi. This makes sense due to the harm that can result if nitro is given to a patient with right sided MI. Nitro assist ensures that the pt has a hx of nitro use. Now, just because you don't carry nitro would not mean that you would not be required to know and understand it's pharmacology - knowing when a protocol/guideline doesn't apply is just as, if not more than knowing when it does.

If you are talking paramedics, at any level then they do and should carry nitro.
Same would go for any fr service which trained the providers in ecg interp and 12 leads - ecg interp is not a regulated act, not taught as part of the amfr scope of practice, but it doesn't make it illegal for an mfr who has received the appropriate training/education to interpret an ecg.

I have no issue with pt assist or giving it if the pt has a script for it. I misunderstood you and thought you were talking about EMTs (PCP)

 

[Av8or007]

Yeah. Obviously paramedics should have basic drugs like nitro.

I do think that things need to change to allow at a minimum asa and epi-pen (or amps of epi via im injection - w appropriate education) administration for all fr's, with glucometry and pulse ox (alberta emr's already do spo2 and blood glucose, pretty basic interventions). This would come with the education required for patient assessment and some pathophysiology and pharmacology education.

In the uk, there are mfr levels that can give those drugs AND use entronox for pain control.

Nitro can be 'scary' in the wrong pts and if the pt doesn't have a hx of nitro use then you shouldn't give it w/o an iv which mfr's can't do - thus the reason why i don't think mfr's should carry nitro (along with a complete lack of education on pathophysiology and pharmacology). To give nitro also requires a 12 (in reality a 15 lead is much better) lead to rule out rvi.

As for asa, salbutamol and epi, these are high benefit, low to medium risk meds that can make a lot of difference. The only med on this list that could be 'nasty' is epi, and only in situations where the pt was not having a severe allergic rxn. For an allergic rxn, epi can be lifesaving.

 

[Veneficus]

Nitro assist is definitely ok, but we shouldn't carry nitro. As a amfr 1 with additional training and knowledge, i am fully in support of us not carrying nitro due to the risks.

Under the Ontario protocols for nitro, a 12 lead is required to rule out rvi. This makes sense due to the harm that can result if nitro is given to a patient with right sided MI. Nitro assist ensures that the pt has a hx of nitro use. Now, just because you don't carry nitro would not mean that you would not be required to know and understand it's pharmacology - knowing when a protocol/guideline doesn't apply is just as, if not more than knowing when it does.

If you are talking paramedics, at any level then they do and should carry nitro.
Same would go for any fr service which trained the providers in ecg interp and 12 leads - ecg interp is not a regulated act, not taught as part of the amfr scope of practice, but it doesn't make it illegal for an mfr who has received the appropriate training/education to interpret an ecg.

Medical device companies must love you guys.

The most common sign of a right sided MI is an abysmally low blood pressure, which contraindicated nitro in EMS anyway. So you really don't need that 12 lead to determine if if there is a right sided MI or not, because you will not be giving the nitro even if they don't have a right sided MI.

Nitro can be 'scary' in the wrong pts and if the pt doesn't have a hx of nitro use then you shouldn't give it w/o an iv which mfr's can't do - thus the reason why i don't think mfr's should carry nitro (along with a complete lack of education on pathophysiology and pharmacology). To give nitro also requires a 12 (in reality a 15 lead is much better) lead to rule out rvi

I think it sounds scary to you because of unfamiliarity with it. It has a very short half life, and even with the most profound effect, an IV is not needed to give a sl dose.

 

[Av8or007]

In the right pts, nitro can do a lot of good, such as ACPE/chf or the right mi pt. The half life is very short, but who wants to create iatrogenic PEA if it can be avoided. Causing a pt to crash from your tx is something we try to avoid at all costs. By running the ekg, you account for the subset of pts that may have a borderline bp.

Contras for nitro in ontario als standards include sbp<90 and HR<60 but less than 159 bpm.

Ontario land protocols require a 12 or 15 lead ekg. You are right though, it depends on if the pt is preload dependent.

An iv is required if no prior hx to allow treatment of hypotension if required.

 

[Veneficus]

In the right pts, nitro can do a lot of good, such as ACPE/chf or the right mi pt.

Ontario land protocols require a 12 or 15 lead ekg. You are right though, it depends on if the pt is preload dependent.

An iv is required if no prior hx to allow treatment of hypotension if required.

That may be the protocol, but I think it is a bit conservative, unless you are using IV nitro.

 

[Medic Tim]

That may be the protocol, but I think it is a bit conservative, unless you are using IV nitro.

this ^^

 

[NomadicMedic]

Agreed. Patients self administer nitro all the time, without the benefit of a line or 12 lead prior.

 

[Clare]

Agreed. Patients self administer nitro all the time, without the benefit of a line or 12 lead prior.

That is basically what we got taught. GTN is not contraindicated in right ventricular infarcts, but it is grounds to give a lesser dose of 0.4 mg SL instead of the usual 0.8 mg and if the patients BP is a little on the low side, give a fluid challenge first or instead of GTN.

A right sided ECG is also a good idea.

GTN is far more useful in patients who have acute pulmonary edema anyway, I don't really think it has much of a role in myocardial infarction unless the patients pain or ST/T wave changes are significantly relieved. I mean they have called us because (potentially) their GTN is not working, so where is the point in giving them more? same goes for if their pain is not significantly relieved then its not working so why keep giving it?

We generally give 0.8 mg SL x 2 sprays five minutes apart and if it doesn't work then we don't give any more; by "work" I mean their pain or ST or T wave changes must be either completely or nearly almost go away; if for example their pain or ST or T wave changes go away or almost go away with GTN and the come back then we give some more GTN but if they do not then we do not keep giving it.

 

[Av8or007]

Interesting, never knew that. Ontario's protocols on some things aren't exactly cutting edge...

E.g. BLS standards still say NRB @ 15 for all. REALLY??!!

The ontario air ambulance service, ORNGE, has protocols that are a lot more aggressive. For example, in those protocols, just like it should be, rvi as determined by a 12 or 15 lead ekg is a relative contra for nitro depending on if the pt is preload dependent and can tolerate a reduction preload from the nitro.
BTW most ems services in ontario have 12 lead capability, so it's not really an issue to use it to check for rv mi, as you are normally going to do a 12 lead in a pt with suspected
mi anyways.


At the same time, i was saying that medical first responders shouldn't carry nitro. Paramedics obviously carry and administer nitro all the time.

 

[NomadicMedic]

I said it before, but I'll say it again because it seems to have gotten lost in the noise of this thread.

The real skills that BLS people need to learn are moving patients safely and effectively, customer service, and courteous, defensive driving.

Once they manage those, maybe then we'll let them touch some medical stuff.

 

[Bullets]

I said it before, but I'll say it again because it seems to have gotten lost in the noise of this thread.

The real skills that BLS people need to learn are moving patients safely and effectively, customer service, and courteous, defensive driving.

Once they manage those, maybe then we'll let them touch some medical stuff.

Ok, ive accomplished those 3 things, no complaints, no accidents in 4 years of EMS work, all patients who were alive when i made contact were moved and transported without incident, over 4k patient contacts

GIVE MEDS PLEASE!!!!!!